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Facts on Osteoporosis

Laurie Taylor, 50, drives to work where she has desk job. Throughout her life, Laurie has played golf and tennis with friends. She enjoys sharing trips, social events and other activities with her family.

Laurie belongs to a women's club. Recently, a local doctor spoke at a club meeting about a disease that Laurie had heard of, yet knew nothing_osteoporosis. Osteoporosis is the bone-thinning disease responsible for the loss of height, stooped posture, and broken hips, that she has seen in so many older women. Her own mother died of complications after surgery to correct a broken hip. Laurie had mistakkenly believed that the hip fracture was simply part of growing older. She now knows she was wrong.

Laurie listened more intently to the speaker as she described the risk factors for osteoporosis. Laurie quickly realized that she is at risk Laurie is a small-framed woman who has begun menopause. She smoked cigarettes until recently, And her mother's experience makes it more likely that she is at risk for osteoporosis.

Immediately, Laurie made an appointment to see her doctor. She discussed her concerns with him. The doctor conducted several tests, including a bone mass measurement.

Laurie's bone mass was already low for someone her age. The doctor prescribed a treatment program that will slow the bone loss and reduce the risk of a broken bone, perhaps even a broken hip, in the future. By visiting her doctor and following his recommendations, Laurie has made it less likely that her bones will become fragile and break.

While the effects of osteoporosis are most often seen later in life, everyone should be concerned about the disease. Proper nutrition and exercise throughout life can dramatically decrease a person's risk of suffering from osteoporosis.

When Jeff McMillan was in his mid-forties, he was diagnosed with chronic asthma. Jeff suffered attacks which made it difficult for him to breathe and forced him to restrict his physical activity. His doctor prescribed an anti-inflammatory steroid, known as a glucocorticoid, which helped alleviate Jeff's asthma attacks. His doctor explained that prolonged use of glucocorticoids can lead to bone loss and that Jeff would have to have routine checkups to assess his bone density and strength.

Jeff's physician monitored his condition on a regular basis. After Jeff had been using the medication for several years, a bone mass measurement showed that he had experienced bone loss. His physician recommended taking immediate steps to slow bone loss while maintaining control of Jeff's asthma.

Jeff could not discontinue his asthma medication without suffering recurring attacks. In this case, Jeff's doctor was able to substitute the oral glucocorticoid with an inhaled form which has fewer bone-thinning side effects. His doctor also started Jeff on a bone-strengthening treatment program which included medication, calcium, and regular exercise to slow the bone loss and reduce Jeff's chances of developing fractures.

Today, doctors know more about the causes of osteoporosis and how to prevent and treat the disease. However, the reason that some patients have unusually severe and progressive osteoporosis is not yet fully understood. Research is continuing in an effort to find the answer to this question as well as to develop new and better treatments.

Definition

Osteoporosis, or porous bone, is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased susceptibility to fractures of the hip, spine, and wrist.

Prevalence

Osteoporosis is a major public health threat for 25 million Americans, 80 percent of whom are women. In the U.S. today, 7-8 million individuals already have osteoporosis and 17 million more have low bone mass, placing them at increased risk for this disease.

P One out of every two women and one in eight men have an osteoporosis-related fracture.

P By age 75, one-third of all men will be affected by osteoporosis.

P  While osteoporosis is often thought of as an older person's disease, it can strike at any age.

P  Osteoporosis is responsible for 1.5 million fractures annu- ally, including:

    •     more than 300,000 hip fractures.

    •     500,000 vertebral fractures

    •     200,000 wrist fractures

    •     more than 300,000 fractures at other sites

Cost

The estimated national direct expenditures (hospitals and nursing homes) for osteoporosis and associated fractures was $10 billion ($27 million each day) and the cost is rising.

Symptoms

Osteoporosis is often called the "silent disease" because bone loss occurs without symptoms. People may not know that they have osteoporosis until their bones become so weak that a sudden strain, bump, or fall causes a fracture or a vertebra to collapse.

Collapsed vertebra may initially be felt or seen in the form of severe back pain, loss of height, or spinal deformities such as stooped posture or dowager's hump.

Risk Factors

Certain people are more likely to develop osteoporosis than others. Factors that increase the likelihood of developing osteoporosis are called "risk factors." The following risk factors have been identified.

    •     Being female

    •     Thin and/or small frame

    •     Advanced age

    •     A family history of osteoporosis

    •     Early menopause

    •     Abnormal absence of menstrual periods (amenorrhea)

    •     Anorexia nervosa or bulimia

    •     A diet low in calcium

    •     Use of certain medications, such as corticosteroids and anticonvulsants

    •     Low testosterone levels in men

    •     An inactive lifestyle

    •     Cigarette smoking

    •     Excessive use of alcohol

    •     Caucasian or Asian, although African Americans and His- panic Americans are at significant risk as well

P Women can lose up to 20 percent of their bone mass in the 5-7 years following menopause, making them more susceptible to osteoporosis. However, 1.5 million American men are affected by osteoporosis and one out of eight men age 50 and older will develop fractures.

P White women 60 years of age or older have at least twice the incidence of fractures as African American women. However, one out of five African-American women are at risk of developing osteoporosis.

Detection

Specialized tests called bone density tests can measure bone density in various sites of the body. A bone density test can:

    •     Detect osteoporosis before a fracture occurs

    •     Predict your chances of fracturing in the future

    •     Determine your rate of bone loss and /or monitor the effects of treatment if the test is conducted at intervals of a year or more

Prevention

Building strong bones, especially before the age of 35, can be the best defense against developing osteoporosis, and a healthy lifestyle can be critically important for keeping bones strong. So, to help prevent osteoporosis

    •     Eat a balanced diet rich in calcium

    •     Exercise regularly, especially weight-bearing activities

    •     Don't smoke and limit alcohol intake

    •     Talk to your doctor if you have a family history of osteoporosis or no longer have the protective benefit of estrogen due to natural or surgically induced menopause

Fractures

P The most typical sites of fractures related to osteoporosis are the hip, spine, wrist, and ribs, although the disease can affect any bone in the body.

P  Forty percent of all women will have at least one spinal fracture by the time they reach age 80. Spinal osteoporosis is eight times more likely to afflict women than men.

P  The rate of hip fracture is two to three times higher in women than men; however, the death rate for men within one year after a hip fracture is 26 percent higher than in women.

P  Spinal osteoporosis is eight times more likely to afflict women than men.

P  A woman's risk of hip fracture is equal to her combined risk of breast, uterine and ovarian cancer.

P  In 1988, about 250,000 Americans age 45 and over were admitted to hospitals with hip fractures. Osteoporosis was the underlying cause of many of these injuries.

P  Individuals suffering hip fractures have a 5 to 20 percent greater risk of dying within the first year following that in- jury than others in their age group.

P  Among those who were living independently prior to a hip fracture, 15 to 25 percent are still in long-term care institutions a year after the injury.

Treatment and Care

Although there is no cure for osteoporosis, there are treatments available to help stop further bone loss and fractures:

    •     Studies have shown that estrogen can prevent the loss of bone mass in postmenopausal women.

    •     Alendronate, a bisphosphonate, has recently been approved by the Food and Drug Administration for treatment of post menopausal osteoporosis.

    •     Calcitonin is a treatment that can be used by women and men for osteoporosis. This drug has been shown to slow bone breakdown and also can reduce the pain associated with osteoporotic fractures.

    •     Treatments under investigation include other bisphosphonates, sodium fluoride, vitamin D metabolites, and selective estrogen receptor modulators.

Medical experts agree that osteoporosis is highly preventable. However, if the toll of osteoporosis is to be reduced, the commitment to osteoporosis research must be significantly increased. It is reasonable to project that with increased research, the future for definitive treatment and prevention of osteoporosis is very bright.

Alice Murray is a petite, 60-year-old woman and a heavy smoker who experienced an early menopause. Alice retired at age 55 from a career as a teacher. Since her retirement, Alice has enjoyed shopping, seeing her friends and spending time with her family. However, she has never liked to exercise. During the last few years, Alice has developed stooped posture and lost more than two inches in height. This change in body image bothers Alice, but she incorrectly assumed it was part of getting older.

Alice has also been experiencing back pain and stiffness. When she began taking over-the-counter pain medication regularly in an attempt to alleviate her symptoms, Alice decided it was time to see her doctor.

After examining Alice, her doctor realized that Alice might be suffering from osteoporosis. Her doctor pointed out that beside Alice's recent loss of height and stooped posture which often indicate the presence of vertebral fractures, Alice has several osteoporosis risk factors: she had an early menopause, is a smoker. is small-boned and thin, and does not exercise. Taking these factors into consideration, Alice's doctor first referred her for a bone mass measurement and then prescribed a treatment program which included a calcium-rich diet, moderate exercise and medication to lessen her pain and help protect her from future fractures.

One way to increase the amount of calcium in your diet is to

eat calcium-rich foods like low-fat milk, cheese, broccoli, and others. If you are unable to get enough calcium through your diet, your doctor can recommend an appropriate calcium supplement. Since there are several different types of calcium and a variety of supplements available, you should discuss the choice of calcium with your doctor.

The calcium in supplements needs to be easily absorbed by the body. You can be sure of this if the tablet dissolves almost entirely in a small glass of warm water or vinegar within 30 minutes. Also read the label to determine the actual amount of calcium in the supplement, which is usually referred to as elemental calcium.

Some people are lactose intolerant and have difficulty digesting milk because they lack the enzyme lactase, which is needed to break down the milk sugar lactose. Milk fermented with certain bacteria (called acidophilus) is well tolerated, as are yogurt and hard cheeses. If you are lactose intolerant, you can treat lactose-containing foods with commercial preparations of lactase or buy milk products that have already been treated.

Getting enough calcium, whether through diet or supplements, is essential to maintaining bone strength and can play a vital role in preventing osteoporosis-related fractures. Speak to a doctor or dietician about how you can get the proper amount of calcium.

Vitamin D plays an important role in calcium absorption and in bone health. The relationship between calcium and vitamin D is similar to that of a locked door and a key. Vitamin D is the key that unlocks and opens the door, allowing calcium to leave the intestine and enter the bloodstream.

Vitamin D is synthesized in the skin through exposure to sunlight. While many people are able to obtain enough vitamin D naturally, studies show that vitamin D production decreases in the elderly, in people who are housebound, and during the winter. These individuals may require vitamin D supplementation to ensure a daily intake of at least 400 IU, but not more than 800 IU of vitamin D. Intake beyond 800 IU should only be exceeded under a doctor's supervision. Massive doses of vitamin D are not recommended.

Exercise can also be helpful in building and maintaining strong bones. Exercise that forces you to work against gravity—so called weightbearing exercises such as walking or jogging—are beneficial. Other weightbearing exercises include racquet sports, hiking, aerobic dance, and stair climbing. The benefits of exercise last only as long as you maintain the program. If you are at risk for osteoporosis, your doctor will most likely include exercise as part of your overall osteoporosis prevention program.

If you have osteoporosis, you might be wondering if you should exercise at all. The answer, for most people, is yes. You should speak with your doctor or ask for a referral to a specialist in physical medicine to learn what type of exercises you can do safely not only to preserve bone, but also to strengthen your back and hips and maintain flexibility. Your doctor will be able to help you design an appropriate exercise regimen. Keep in mind, however, that exercise alone cannot prevent or cure osteoporosis.

You can take steps now to prevent broken bones later. By preventing the debilitating effects of bone loss, you can look forward to a healthy, active life. If you have already suffered a broken bone, a treatment program can slow further bone loss and reduce the likelihood of additional fractures.

Medications Used to Prevent and Treat Osteoporosis

Currently, estrogen, calcitonin, and alendronate are approved by the U.S. Food and Drug Administration (FDA) for the treatment of postmenopausal osteoporosis. Estrogen is also approved for the prevention of osteoporosis. These medications affect the bone remodeling cycle and are classified as antiresorptive medi cations. Bone remodeling consists of two distinct stages: bone resorption and bone formation. During resorption, special cells on the bone's surface dissolve bone tissue and create small cavities. During formation, other cells fill the cavities with new bone tissue. Usually, bone resorption and bone formation are linked so that they occur in close sequence and remain balanced. When osteoporosis is present, the balance is altered and bone loss occurs.

Anti-resorptive medications slow or stop the bone resorbing portion of the bone-remodeling cycle but do not slow the bone-forming portion of the cycle. As a result, new formation continues at a greater rate than bone resorption, and bone remodeling cycle but do not slow the bone-forming portion of the cycle. As a result, new formation continues at a greater rate than bone resorption, and bone density may increase.

Estrogen Replacement Therapy (ERT) and Hormone Replacement Therapy (HRT)

Estrogen replacement therapy (ERT) is the only medication approved for both the prevention and treatment of osteoporosis. ERT has been proven to not only reduce bone loss but to also reduce the number of hip and spinal fractures in postmenopausal women. ERT is administered most commonly in the form of a pill or skin patch and is effective even when started after age 70. When estrogen is taken alone, it can increase a woman's risk of developing cancer of the uterine lining (endometrial cancer). To eliminate this risk, physicians prescribe the hormone progestin in combination with estrogen (hormone replacement therapy or HRT) for those women who have an intact uterus. ERT/HRT relieves menopause symptoms and has been shown to have beneficial effects on both bone health and cardiovascular health. Side effects may include nausea, bloating, breast tenderness, and high blood pressure. Some studies indicate a relationship between estrogen use and breast cancer, while other studies indicate no relationship at all. The issue of a relationship between breast cancer and estrogen use is still to be determined.

Calcitonin

Calcitonin is a naturally occurring hormone involved in calcium regulation and bone metabolism. It slows bone loss, and anecdotal reports indicate that it relieves the pain associated with bone fractures. Because calcitonin is a protein, it cannot be taken orally as it would be digested before it could work. Calcitonin is available as an injection or nasal spray. While it does not affect other organs or systems in the body, injectable calcitonin may cause an allergic reaction and unpleasant side effects including flushing of the face and hands, urinary frequency, nausea, and a skin rash. The only side effect reported with nasal calcitonin is a runny nose.

Alendronate

Alendronate is a newly approved medication from the class of drugs called bisphosphonates. Research studies using alendronate to treat postmenopausal women with osteoporosis showed that alendronate produced small increases in bone density in both the spine and hip. Side effects are uncommon but may include abdominal or musculoskeletal pain, nausea, heartburn, or irritation of the esophagus. Like all bisphosphonates, alendronate must be taken on an empty stomach. The manufacturer strongly recommends taking this medication with a full glass of water first thing in the morning and then waiting at least one-half hour, and preferably one hour, before the first food, beverage, or medication of the day. To minimize side effects, the manufacturer urges people to remain in an upright position for at least one half hour after taking this medication.

Source: National Osteoporosis Foundation

Reprinted with permission