What is osteoporosis?

Osteoporosis is a skeletal disease characterized by low bone mass, and the deterioration of bone architecture leading to bone fragility and increased risk of fracture. Bone normally rejuvenates itself through a process of bone absorption and formation called bone remodeling. Osteoporosis occurs when bone breakdown, or absorption, occurs at a rate greater than bone formation. Osteoporosis means "porous bones". It is a condition in which the bones become fragile and weakened, increasing the risk of fractures, especially in the wrist, hip and spine. Any bone can be affected, but the most serious concerns are fractures of the hip and spine. If hypertension is the silent killer, then osteoporosis is the silent thief, insidiously robbing the skeleton of its banked resources often for decades until the bone is so weak that it cannot withstand normal mechanical stress.

 

Why is osteoporosis such an important problem?

In developed countries, osteoporotic fractures has been labeled as an “orthopaedic epidemic” as the populations in these countries ages. It affects an estimated 75 million people in the USA, Europe and Japan combined. Osteoporosis causes more than 1.5 million fractures each year, including more than 300,000 hip fractures and 700,000 vertebral fractures. One in two women over the age of 50 and one in eight men over age 50 will have an osteoporosis‐related fracture in their lifetime.

 

How does osteoporosis develop?

Bone is living, growing tissue composed of a network of collagen fibers inlaid with calcium and phosphate. The minerals are mixed with water to form a hard cement‐like substance called hydroxyapatite. Calcium is the principal ingredient of hydroxyapatite. Calcium also plays an important role in transmitting signals to nerves and muscles and is therefore important in regulating heart rate, muscle contractions, blood pressure and other bodily functions. In order to keep these functions regulated, the calcium stored in the blood must be maintained at certain levels. When calcium in the blood drops too low, it is replenished with calcium from the bone. Resorption, the process by which calcium is released from the bone into the blood, results in the breakdown of bone. It is coupled with another process called formation in which bone is rebuilt. Together, the two processes constitute bone remodeling. The continuous remodeling cycle serves to supply the body with needed calcium and to maintain the skeleton by replacing old bone with new. When formation exceeds resorption, bone mass increases. When resorption takes place faster than formation, bone mass loss occurs. If excessive bone loss continues over time, osteoporosis develops. During the early years of life, formation is greater than resorption and bone mass increases. Maximum, or peak, bone mass is reached around age 30. After that time, bone is removed faster than it can be replaced and bone mass decreases. While gradual bone loss is a normal part of aging, it is those individuals who fail to achieve optimal peak bone mass and those with accelerated bone loss who are at greatest risk for osteoporosis.

 

Am I at risk of developing osteoporosis?

There are many factors that can increase a woman's risk of osteoporosis. A few of the risk factors are:

• Postmenopausal
• Ethnicity‐Caucasian and Asian
• Family history
• Petite, small frame
• Eating disorders
• Caffeine
• Smoking
• Excessive use of alcohol
• Vitamin D deficiency
• Inactivity
• Thyroid disease
• Chronic steroid use

What are the symptoms of osteoporosis?

Osteoporosis is often called the "silent" disease, because it can progress without symptoms. Without proper screening and diagnosis, a person may not know they have osteoporosis until they break a bone. Fractured bones were once the only way to tell if a person had osteoporosis. Fortunately, there are new methods today that can detect osteoporosis before a fracture occurs.

 

Do I have osteoporosis?

In order to demonstrate bone loss, a bone scan would need to be performed. The most common type of bone scan is a DEXA test which would provide a value of Bone mineral Density (BMD). A bone scan is recommended for all women over 65 years old. In addition, women with risk factors other than menopause, postmenopausal women with a history of a fracture and women considering therapy for osteoporosis should speak to their health care providers about early testing.

 

WHO defined (a) Normal BMD as values >1SD (standard deviation) below to the young normal adult mean, (b) “Osteopaenia” as value between ‐2.5SD and ‐1SD, (c) “Osteoporosis” as BMD <‐2.5SD and (d) “Establishedor Severe Osteoporosis” is BMD below ‐2.5SD in the presence of fractures

 

How does osteoporosis affect people who have it?

The biggest concern for people with osteoporosis is the risk of bone fractures. Once a fracture occurs, a person’s independence, quality of life and even survival can be greatly reduced.

 

Fractures of the spinal vertebrae, called compression fractures, lead to a progressive change in the shape of the spine and back. Vertebrae may crush suddenly without warning. A person may lose height or develop a pronounced curvature of the spine, known as a "dowager’s hump". A person may not want to participate in daily activities, such as walking, lifting objects, dressing, housecleaning, shopping and other simple pleasures of life, for fear of fracturing a bone or because the pain is too great. The loss of self‐esteem caused by changes in body image, the loss of independence and the fear of future fractures can lead to depression and increasing isolation.

 

Probably the most serious consequences arise from hip fractures. A hip fracture almost always leads to surgery and hospitalization and can result in lengthy or permanent nursing home stays, numerous visits to rehabilitation centers, pain and physical disability, inability to perform daily living activities and loss of independence. These factors, alone or in combination, lead to deterioration in emotional health and social life.

 

Can anyone get osteoporosis?

Yes, although certain people are more likely to develop osteoporosis than others. Risk factors that increase the likelihood of developing osteoporosis may be related to your body type, your family history, or your lifestyle behaviors, or some combination of these three factors. However, about 30% of individuals with osteoporosis have no identifiable risk factors.

 

How can I prevent/treat osteoporosis?

Treatment and prevention of osteoporosis depends on the severity of the disease. The first line of prevention is calcium supplementation and exercise. Medications can also be added if additional protection from osteoporosis is indicated.

 

How do I know if I am at risk for getting osteoporosis?

There are two types of "risk factors" which increase the likelihood of developing osteoporosis. The first type of risk factor is called "internal" or uncontrollable, because these are factors that occur naturally, rather than through personal choice. These factors include:

 

• Thin or small‐frame. Individuals with smaller bones have less bone mass to lose. In addition, less body weight generally results in less stress and stimulation of the skeleton.
• Early estrogen deficiency. Early estrogen deficiency occurs in women experiencing menopause before age 45 and in girls and premenopausal women with amenorrhea.
• Menopause. Menopause is the single most important risk factor for osteoporosis. Even without any other risk factors present, postmenopausal women are at high risk for developing the disease.
• Low testosterone levels in men. Androgen deficiency in men may have the same effect on bone mass loss as estrogen deficiency in women.
• Gender. Women experience osteoporosis four times as frequently as men and at an earlier age due to decreased estrogen levels at menopause and being smaller framed in general.
• Age. Gradual bone loss is a normal part of aging, although it need not always result in osteoporosis.
• Ethnicity/Race. Asian, Native American, white Hispanic and white non‐Hispanic women are at highest risk, although African‐American and non‐white Hispanic women are still at significant risk.
• Family and personal history. A family history of osteoporosis or personal history of previous fracture may indicate increased risk for developing osteoporosis.

The second type of risk factor is "external", or controllable, risk factors because making certain lifestyle choices can reduce or eliminate these factors as risks. These factors include:

 

• Inadequate calcium and Vitamin D intake. Poor calcium intake at any age can increase the risk of osteoporosis. Vitamin D is essential for absorption of calcium by the body.
• Sedentary lifestyle. Weight bearing exercise, such as walking, has a stimulating effect on the skeleton and can increase bone formation in the presence of adequate calcium. However, too much exercise in premenopausal girls and women can lead to amenorrhea and decreased estrogen production.
• Cigarette smoking. Tobacco lowers estrogen in women and may have a similar effect on sex hormones in men. In addition, tobacco is believed to have a toxic effect on bone or the cells that make bone.
• Excessive alcohol intake. Excessive alcohol intake can interfere with the absorption of nutrients needed to preserve bone as well as lead to malnutrition and falls due to unsteady gait.
• Excessive intake of caffeinated beverages. More than 2‐3 cups each day of beverages containing caffeine, such as coffee, tea and colas, can lead to excess calcium losses and increased risk of osteoporosis.
• Eating disorders. Disorders such as anorexia nervosa and bulimia can lead to inadequate intake or excessive elimination of bone‐building nutrients.
• Prolonged use of certain medications. Glucocorticoids, a group of anti‐inflammatory medications used to treat conditions such as asthma, arthritis and some cancers, as well as excessive thyroid hormone and some anticonvulsants, can lead to bone mass loss.

 

How much calcium should I take?

Calcium should be taken after meals in divided doses of no more than 500mg. Calcium should be taken with vitamin D 400‐800 IU.

 

The table below lists the recommended dose based on age.

 

Age	Daily Dose
1 to 10	1000mg/d
11‐18	1200mg/d
18‐50	1000mg/d
>50	1200mg/d

 

To increase your daily intake of calcium, select a variety of the following foods:

 

• low‐fat or fat‐free dairy products including milk, cheese and yogurt
• soybeans and tofu
• dark green vegetables, including broccoli, kale, turnip and collard greens
• sardines and salmon with bones
• calcium‐fortified foods and juices.

To help your body use the calcium you get:

 

• avoid excess animal protein, sodium, alcohol and caffeine since these items can cause you to lose calcium
• eat a balanced diet with a variety of fruits, vegetables, whole grains and low‐fat or fat‐free calcium‐rich foods.

It is best to try to get your calcium through the food that you eat. However, the calcium in supplements can also be readily used by your body and can help you to get adequate calcium if you are not able to get enough from your diet.

 

Can osteoporosis be prevented?

Yes, but prevention involves a lifelong effort, starting in early childhood. One of the most important factors in preventing osteoporosis is achieving optimal peak bone mass during childhood, adolescence and early adulthood. Much of the peak bone mass achieved is determined genetically. However, there are several controllable factors that can increase bone mass. These include a balanced diet adequate in Vitamin D and calcium and weight‐bearing exercise.

 

It is also important to maintain the bone mass achieved as a child to help prevent osteoporosis. This requires adequate calcium intake, weight‐bearing exercise, and avoiding tobacco and excessive alcohol intake.

 

At around 40‐45 years of age, it becomes important to stop the age‐related bone loss that occurs. This includes adequate calcium and vitamin D intake, weight‐bearing exercise and hormone replacement.

 

Why is Vitamin D important in preventing osteoporosis?

Vitamin D can be thought of as the "key" that unlocks the door to the body to let calcium in. Without Vitamin D, your body can’t use calcium very well, even if you get enough calcium in your diet.

 

The exact optimal daily dose of Vitamin D has not been determined, but most experts recommend that you get 400‐800 IU of Vitamin D each day. Less than 400 IU per day will keep you from getting full benefit from the calcium in your diet. More than 800 IU per day may be harmful.

 

There are two ways to get Vitamin D:

 

• Vitamin D is formed naturally in your body after exposure to sunlight. About 15 minutes in the sun each day will make all the Vitamin D your body needs.
• You can also get Vitamin D from the foods you eat. Food sources include Vitamin D fortified dairy products, egg yolks, saltwater fish and liver. Most standard multi‐vitamins contain adequate amounts of Vitamin D and many calcium supplements also contain Vitamin D.

If you are elderly, do not get outside often or you live in the North during the winter, you may need to consider a supplement if adequate Vitamin D cannot be obtained from the diet. If you are taking a multi‐vitamin or calcium supplement containing Vitamin D, make sure that your vitamin D intake from all sources does not exceed 800 IU.

 

How much exercise do I need to protect myself from osteoporosis?

Exercise stimulates the bone remodeling cycle. Weight bearing exercises such as weight training, running, walking, biking and cross country machines will provide both aerobic and weight bearing exercise.

 

Exercise is an important part of keeping your bones healthy and can help maintain bone mass. Any exercise that causes your body to work against gravity or exerts resistance against the body is effective.

 

Weight‐bearing exercise is the most beneficial exercise for maintaining bone mass. Weightbearing exercises are also popular because they are simple and do not require learning new movements or any cash outlay. Examples of weight‐bearing exercises include walking, hiking, dancing, tennis and stair climbing. You should try to perform at least one of these exercises for approximately 45 minutes a day at least 3‐4 days a week.

 

Strength‐training exercise, which uses weights for resistance, helps strengthen muscles. Strength training can be done at home with free weights or at a gym using weight machines. Weight training must be done correctly to get good results and to avoid injury.

 

Other exercises, such as swimming and cycling, do not benefit bone strength but are beneficial for your heart and lungs and help maintain or improve mobility.

 

You don’t need to become an athlete to benefit from exercise. Just make weight‐bearing activity part of your everyday life. Even if you already have osteoporosis, you can benefit from exercise.

 

REMEMBER: Always check with your doctor or health care provider before starting a new exercise program.

 

What medications are used to treat osteoporosis?

There are several medical treatments for osteoporosis. Estrogen therapy has been used to treat osteoporosis for many years. Newer non hormonal treatment options are now available, these are the bisphosphonates, alendronate and risedronate, raloxifene, a selective estrogen receptor modulator, parathyroid hormone and calcitonin. Talk to your health care provider to determine the best treatment option for you.