Osteoporosis

Forty-four million Americans are affected by weak bone, the majority of which are over the age of 50. Ten million American are afflicted with osteoporosis while approximately 34 million more are projected to have low bone mass, know as osteopenia, placing them at high risk for osteoporosis. The majority of those affected by osteoporosis are women. Fractures related to osteoporosis are very common in those over the age of 50.

To keep bones strong the body needs specific nutrients and hormones. Calcium and Vitamin D are the two most important nutrients preventing osteoporosis. Calcium is a mineral that is critical to bone building. Vitamin D helps the body utilize calcium. The hormones estrogen, testosterone, parathyroid hormone, calcitonin and growth hormone, play an important role in bone health.

Osteoporosis occurs without symptoms. The first symptom is often a minor stress that causes a vertebra to collapse or a hip to fracture. The disease is associated with bones that are thin and less dense.

Fractures

Fracture, the most dreaded complication of the osteoporosis, leads to significant complications such as extended or permanent immobility, increases risk of developing several diseases and increases risk of death. Osteoporosis is responsible for more than 1.5 million fractures each year with women being affected much more than men. The hip, spine and wrist are common sites of fracture. Fracture is a top cause of nursing home placement and permanent disability. After a fracture many patients are unable to walk without the aid of a cane. This reduction in mobility sets the body up for many diseases.

Risk Factors

Several factors put people at risk for osteoporosis. If you have risk factors for osteoporosis it is important to communicate this with your doctor to get proper preventative screenings and treatment. In addition, if you are at risk it is important that you live a lifestyle that is consistent with positive bone health. The three most important risk factors include being of low body weight, older age and having no estrogen. See the list below for risk factors associated with osteoporosis.

Signs and symptoms

Despite its high prevalence, there are few symptoms that define the disease. Broken bones are unfortunately often how the disease is first detected. Common broken bones include: the hip, forearm or vertebrae. A reduction in height accompanied by a hunched over stance, due to thinning of the vertebrae, may also be a clue that osteoporosis is present. Back pain is a frequent complication of a compression fracture, which occurs frequently in patients with osteoporosis.

Diagnosis

Patients with multiple risk factors need to be screened for osteoporosis. The best way to screen for and diagnose osteoporosis is by taking a picture of the bones known as a Dual-energy x-ray absorptiometry (DEXA) scan. A DEXA scan, which takes 10-20 minutes, is an x-ray that evaluates the density of bones.

The test compares bone density to a 25-30-year-old. A score (called a T-score) is reported, with an average bone density score of 0. The score of zero is what is considered a normal bone density of a 25-30 year old. Scores above zero indicate more dense bones than the average 25-30 year old. Scores less than zero indicate less dense bones than the average 25-30-year-old.

Osteopenia (bones that are thinner than average but not thin enough to be classified as osteoporosis) is diagnosed when the T-score falls between -1.0 and –2.4. Individual who have T-scores less than or equal to –2.5 have osteoporosis.

When osteoporosis is suspected blood work to rule out specific causes of osteoporosis is often done. This blood work includes: blood counts, kidney and liver function tests, electrolytes, calcium, thyroid test, vitamin D levels, hormone levels including testosterone in men and parathyroid hormone and a urine test for calcium and creatinine. While these tests are not done in everyone it can help rule out secondary causes of osteoporosis.

A bone density test can:

Prevention

Prevention is a critical aspect in the management of osteoporosis/osteopenia. Prevention methods revolve around exercise, diet and lifestyle choices.

Exercise can profoundly increase bone strength and reduce the risk of fracture. Exercise where weight is placed on the bones (e.g. walking, jogging) is most effective in improving bone strength. Exercises that do not stress the bones with direct weight – such as swimming and bike riding – are still effective at improving fitness and improving heart health, but are not ideal treatment options for osteoporosis treatment. Weight training (weight lifting or calisthenics) builds the strength of the bones and is especially important for building bone strength in the upper body.

Calcium and vitamin D or supplementing with these nutrients is a well-established method to treat and prevent osteoporosis/osteopenia. Foods high in calcium include dairy products such as milk, cheese, and yogurt. Vitamin D is found in many fortified foods and liver, egg yolks and some fish. Much of the vitamin D is gotten through sunlight. Exposing the hands and face to 10-15 minutes of sun a few times a week will help assure adequate levels of vitamin D.

Most American diets are not high enough in calcium and vitamin D, therefore, supplementation is usually required. Ingesting at least 1200 mg of calcium and 700-800 IUs of vitamin D is the recommendation to treat and prevent osteoporosis.

By about age 20, the average woman has acquired 98 percent of her skeletal mass. Building strong bones during childhood and adolescence can be the best defense against developing osteoporosis later. There are five steps, which together, can optimize bone health and help prevent osteoporosis. 

• A diet high in calcium and vitamin D
• Regular exercise which includes weight-bearing exercise and weight training
• Do not smoke or consume excessive alcohol
• Discuss bone health with your health care provider
• Appropriate use of bone density testing and medication

Treatment

When osteoporosis is diagnosed there are a variety of treatment options. Lifestyle changes – as listed above– are a cornerstone in the treatment of osteoporosis.

Medicines to increase bone strength include bisphosphonates – alendronate (Fosamax); risedronate, (Actonel); Ibandronate (Boniva®) -, Calcitonin, and estrogen.

Bisphosphonates are the most popular drug prescribed for the treatment of osteoporosis. These drugs work by decreasing the break down of bone. These drugs are formulated so they can be taken once a day, once a week or even once a month. Bisphosphonates should be taken in the morning, on an empty stomach and the patient should not lie down or eat for 30-60 minutes after taking the medicine. It should also be taken with a full glass of water. The major side effects include irritation of the gastrointestinal tract. Patients with significant kidney dysfunction should not use this class of medications.

Calcitonin (Miacalcin) decrease the amount of bone being broken down. This drug is given as an injection or a nasal spray. It is not as effective as bisphosphonates. Side effects of this drug include nausea, flushing, diarrhea and nasal irritation.

Estrogen can be used to treat osteoporosis but has lost some favor over the last few years because there is an increased risk of cardiovascular complications when on this drug. The Selective Estrogen Receptor Modulator (SERM), Raloxifene (Evista), is a popular form of estrogen modulation used to treat osteoporosis. This medication is known to improve bone density but has not proven to be the best treatment option for fracture prevention. It is often used in those at high risk for breast cancer.Parathyroid Hormone is a more expensive option that has been used in recent years. Teriparatide (Fortéo) is the drug in this class currently available. It is give by shot one time a day and is an expensive option to treat osteoporosis. Parathyroid hormone is approved for the treatment of osteoporosis in men who are at high risk of fracture.


Health Care Responsibility

• Do you have any risk factors for osteoporosis? If the answer is yes, talk to your doctor about the need for testing for osteoporosis and what can be done to reduce risk including diet and exercise.
• If you have osteoporosis or osteopenia ask your health care provider the questions listed below. You can use the worksheet in the appendix to help.

  Questions to ask you health care provider

  What is my T-score? The T-score helps you understand how thin your bones are. It also helps gauge how well you are responding to therapy.

  What caused this disease in me? Most individuals develop osteoporosis due to multiple risk factors. Having a conversation with your doctor will help you understand what caused your disease and help you reduce risk factors.

  What are my risk factors for this disease? Knowing your risk factors will help you determine the best way to treat your disease and prevent risk for further complications.

  When will I have my next DEXA scan? A DEXA scan – will give you your T-score – and gauges the severity of the disease. It will also help one assess response to therapy.

  Could I benefit from medicines to increase my bone density? The most popular medicines to treat osteoporosis are bisphosphonates. If you are unable to take this type of medicine there are other medicines that can help.

  How much calcium/vitamin D should I take in a day? It is recommended that everyone over the age of 65 take in at least 1200 mg of calcium a day. Calcium supplements have between 250-500 mg of calcium in them. Taking three 500 mg tablets is a common prescription but many people take one to two pills a day and assure that they get adequate calcium and vitamin D in the diet by eating foods, such as dairy products, that are rich in calcium and vitamin D. Vitamin D should be taken in doses of at least 700-800 IU a day

  What type of exercise should I do? How often should I exercise? Weight bearing exercise is the most beneficial type of exercise to increase bone density. Weight training is another good form of exercise to strengthen the bones.