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Osteoporosis

We often associate osteoporosis with the elderly and tend not to think about it until we get older. Actually, osteoporosis is something we might want to consider much earlier, as acting now can help to reduce one's risk of developing this often crippling illness. Osteoporosis affects three million men and women in the UK. With an aging population, the condition is likely to become more common. Osteoporosis can have a devastating effect on an individual's health. It increases the risk of suffering severe fractures from relatively minor trauma, resulting in disability, immobility, chronic pain and even death.

What is osteoporosis?

Osteoporosis is a bone disease which results in a reduction of the total mass of bone and a weakening of the bone's architecture. Someone who suffers from osteoporosis would have bones which are prone to fracture with only minimal force. Though osteoporosis is more common as we get older, it should not be thought of as a normal part of aging. Osteoporosis is a disease. Every effort should be taken reduce the risk of developing it.

Am I at risk of developing osteoporosis?

Up until the age of thirty, a person's bones get stronger and stronger, but after that point, they gradually weaken and become less dense. .

Your skeleton can be thought of as a savings account. The more you save now, the more you will have to spend later in life. Investing in your bones will help reduce the risk of developing osteoporosis and suffering fractures later in life.

The following is a list of the factors that increase your risk of developing osteoporosis:

Age >60
Female sex
Family history
Caucasian or Asian origin
Smoking
Lack of weight bearing exercise
Early menopause
Long term steroid use
Low body mass index (BMI)

How can I avoid developing osteoporosis?

You can reduce the likelihood of developing osteoporosis by making lifestyle changes which tackle some of the modifiable risk factors in the above list, such as smoking, exercise, nutrition and treatment of early menopause.

Smoking: A recent analysis of available research found that bone mineral density was on average 2% lower in smokers for each increasing decade after the menopause in women, along with a 6% difference at the age of 80 (ref: SIGN). The level of risk of developing osteoporosis was shown to decrease after smoking cessation, although it did not significantly drop until 10 years after the last cigarette.

Exercise: There have been many studies that have shown that exercise throughout your life has a positive impact on bone mineral density. Those with sedentary lifestyles, especially during their adolescence, are thought to be at far higher risk of developing osteoporosis later in life.

Diet: Women with a regular dietary intake of milk throughout their lives had a higher bone mineral density after the menopause. Furthermore, diets high in vitamin D also indicated beneficial results in both men and women aged over 80.

Early Menopause: The female sex hormone oestrogen appears to protect women from many conditions, including osteoporosis. Women who suffer an early menopause loose this protection and may want to consider taking hormone replacement therapy (HRT).

As well as the above risk factors, there are also medical conditions that promote osteoporosis. These include hyperparathyroidism, coeliac disease, inflammatory bowel disease, kidney disease and rheumatoid arthritis. If you suffer with any of these conditions, you may be at an increased risk of developing osteoporosis and should discuss this with your doctor.

How is osteoporosis diagnosed?

Doctors may suspect the diagnosis of osteoporosis in a patient who has suffered a fracture, especially where one wouldn't typically associate such an injury. Osteoporosis must also be considered in women who have had an early menopause and may not have been on HRT. Occasionally even x-rays may provide some evidence of osteoporosis.

To accurately diagnose osteoporosis, doctors need to know what the density of the bone. The best test used to ascertain this is called a Duel-Energy X-ray Absorptionmetry, or DXA for short (sometime abbreviated to DEXA). The DXA scan usually aims at looking at two sites, usually the spine and the hip. Results are reported in the form of t and z scores. The t score compares the density of your bones with that of an 18 year old of the same sex and weight. The z score compares the density of your bones with what they should be at your age, sex and weight. The diagnosis of osteoporosis is based on the t-score. These results can be interpreted in 3 ways:

Normal
Osteopenia
Osteoprosis

Osteopenia can be thought of as an intermediary stage, and if identified, actions may be taken toward preventing the development of full-blown osteoporosis.

Doctors may also request blood results in order to highlight underlying conditions responsible for the osteoporosis or even finding other bone diseases.

How is osteoprosis treated?

Osteoporosis treatment is usually limited to women who are post menopausal or who have had an early menopause. Women who are still menstruating, and men who have been found to have osteoporosis, usually require further investigations to identify other underlying conditions. Treating the underlying condition is then the priority. The exception to this is patients on long term corticosteroids, who are at significant risk of steroid induced osteoporosis. They would normally be put on a combination of the treatments outlined below to prevent osteoporosis or reduce the risk of fracture in existing steroid induced osteoporosis.

The aim of treatment in patients with osteoporosis is to reduce the risk of fractures, usually by preserving bone mineral density. Preventative strategies are also important. Below are some treatments to reduce the rate at which bone density is lost. Some of these may even increase bone density, but only slightly.

Exercise: Research has shown that low impact weight bearing exercise, such as walking, is an important aspect of managing osteoporosis. Low impact is defined as always having one foot on the floor, whereas with high impact activity, at some point both feet are off the ground (like when skipping or running). High impact exercise is not recommended for patients with osteoporosis. High resistance strength training may also prove beneficial, as it leads to both gains in strength and bone mineral density. If you do have osteoperosis, it is very important to discuss any program of weight training with your doctor. Exercising under the supervision of a trainer with knowledge of your condition is also important.

Diet: Dietary derived sources of calcium are not only important in prevention, but they also play a fundamental role in the treatment of osteoporosis. In fact, one study showed women with osteoporosis who had a dietary intake of 1000mg of calcium had a 24% reduction in fracture risks. Studies also found that calcium taken from your diet was just as effective as taken in the form of supplements. The Scottish Intercollegiate Guidelines Network recommends that women with osteoporosis take 1000mg of calcium per day. This recommended dose can be achieved by the following:

1 Pint of milk
50g of hard cheese
1 pot of yoghurt
50g of sardines

As for soy, there has been some research looking into compounds found in soy products, called flavanoids, which have been speculated to be beneficial for patients with osteoporosis. As of yet, there is not enough evidence justifying it as a viable treatment.

It is also inconclusive weather or not alcoholic drinks and caffine have a detrimental effect on bone mineral density. This will only be clarified by further research.

Mineral supplements: There is no evidence that taking calcium supplements is better than calcium from dietary sources. In my personal opinion, as I doctor, I have always felt that it is better to obtain your vitamins and minerals naturally, as part of a healthy and balanced diet. If you have a particular problem calcium rich products, then supplements are a valid alternative. In terms of vitamin D, evidence suggests that for active people under the age of 65 with osteoporosis, there is no benefit. Those over the age of 65, however, may see some benefit from taking supplements. Patients with osteoporosis can obtain combined vitamin D and calcium supplements from their doctor on prescription.

Bisphosphonates: This class of drug is regarded as the cornerstone of medical osteoporosis treatment. The most commonly prescribed bisphosphonate in the UK is Alendronic acid. Bisphosphonates inhibit a particular type of bone cell that is responsible for breaking down bone and releasing minerals like calcium in to the blood. Bisphosphoantes inhibit these cells, preventing the breakdown of bone and preserving bone mineral density.

Hormone replacement therapy (HRT): In general, HRT is not recommended as a first line treatment for osteoporosis. If the patient is also suffering with menopausal symptoms which necessitate the use of HRT, then of course prescribing HRT is indicated. This type of treatment, however, will need to be assessed regularly. HRT has been shown to reduce the risk of fractures, but this must be balanced against the increased risk of developing cancers like breast and ovarian cancer, as well as a slight increase in the risk deep vein thrombosis with taking HRT on a long-term basis.

Raloxifene: These drugs belong to a group of drugs called SERM, selective oestrogen receptor modulators. This means that the drug is able to mimic the beneficial effects of oestrogen (HRT) on bone tissue, but has little or no effect on breast and the uterus; hence, avoiding the potentially increased risks of breast and uterine cancer associated with HRT. The drug has been shown to reduce the risk of fractures of the spine in those with osteoporosis, but not other bones. For this reason, unless bisphosphonates cannot be tolerated, Raloxifene is not recommended as a first line agent.

Calcitonin: Calcitonin is a hormone made by our own bodies. It is also synthetically manufactured and can be used by doctors to prevent fractures in osteoporosis by inhibiting bone cells which break down bone. Evidence for this treatment does show a reduction in the risk of fractures of the spine, but not in other bones. It was, however, shown to reduce pain associated with existing vertebral fractures, and therefore it may be suitable for particular patients.

Strontium ranelate: Strontium ranelate is a compound of the element strontium. It has been shown to increase bone formation and inhibit the break down of bone, hence increasing bone mineral density and reducing the risk of fractures. According to NICE, their guidance permits the use of strontium only in cases where postmenopausal women are unable to tolerate bisphophonates. After being challenged in a recent court case, NICE has been asked to review their advice about only prescribing this drug in cases of severe osteoporosis and where cheaper treatments are not tolerated.

Conclusion

Invest in your bones now. Lead an active lifestyle with plenty of weight bearing exercise. Keep your bones strong by ensuring that your diet has the recommended daily amount of calcium and vitamin D. If you have a strong family history of osteoporosis, are approaching the menopause, or if you have recently suffered a fracture after very a minor accident, do speak to your doctor about osteoporosis.

Sources

1. Scottish Intercollegiate Guidelines Network, Management of Osteoporosis. A National Clinical Guideline. Available at http://www.sign.ac.uk/pdf/sign71.pdf (Accessed on 19/05/2010).

2. National Institute for Health and Clinical Excellence, Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women . Available at http://www.nice.org.uk/nicemedia/live/11746/47176/47176.pdf (Accessed on 19/05/2010).

3. National Institute for Health and Clinical Excellence, Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (amended) Available at http://www.nice.org.uk/nicemedia/live/11748/47177/47177.pdf (Accessed on 19/05/2010).

Author: Dr Shazan Chughtai, MB BS

Editor: Dr Hanny Anwar BMedSci, MB BS, MRCS

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