What is Osteoporosis?
The most common type of bone disease is Osteoporosis, a degenerative skeletal disease. Bone density decreases over the years and bones become porous, brittle and break easily. Bone is characterized by three dimensional micro-architecture infused with hormones and minerals. Defects in bone tissue occur when the bone thins or loses volume. Osteoporosis usually happens over time when estrogen decreases for women and testosterone decreases in men. Systemic skeletal remodeling continues without intervention and treatment. Bone strength decreases, bones become brittle and susceptible to breaking after minimal trauma.
Brittle bones often go undetected until a fragility fracture occurs. People often do not have symptoms or signs until then. When a fracture occurs, the pain and disability places a burden on the person and family. Osteoporosis affects up to 1 in 2 women and 1 in 5 men. Identifying those individuals with the greatest risk of fracture is important in order to stop bone loss with pharmacological therapy and movement therapy.
An aging population is increasingly putting stress on health services and the economy. Osteoporosis is quickly becoming a major health burden worldwide. In the last decade, 10 million Americans and 2 million Australians were diagnosed with brittle bone disease. Fractures of the hip, wrist, or vertebra are the most common. Greater incidence is seen in white postmenopausal women, but men are also susceptible to fragility fractures.
Quality of Life
The quality of life (QoL) of patients is often diminished, especially for those who suffer hip fractures. Vertebral fractures are the second worst type of osteoporotic fracture, followed by wrist fractures. Researchers have identified the top four worst countries for quality of life are Lithuania, Italy, Russia and Mexico. Austria and Sweden also offer low QoL to their citizens with osteoporosis. All countries have a reduced QoL when the patient is hospitalized.
Experts forecast that the incidence of osteoporosis will increase by as much as 1/3 by the year 2050. Underdeveloped countries especially will have difficulties reaching their rural populations, as testing, prevention and treatment is often confined to big cities. Even for the richer countries, insurance only partially pays for drug treatment, making it unaffordable for most people. Experts warn of an alarming spike in aging populations, which predicts the number of fractures and deaths due to osteoporosis. Europe is expected to increase its elderly population from 17 percent to 30 percent by the year 2050. Asia is expected to have 8 times the number of elderly by 2050.
Experts find that a combination of several factors is responsible for deficits in implementing quality care in countries. Treatment and quality of life varies from country to country due to inadequacies in identifying people at risk for fracture. Some countries do not have adequate resources for bone mineral testing. Those who are tested may not be adequately identified as osteoporosis candidates. Funding is limited for diagnostic testing. Implementation of policies can be difficult even when funding, testing, diagnosis and treatment are adequate. Finally, half of all patients do not take their medications after a year.
Types of Osteoporosis
Osteoporosis is usually a primary condition due to aging, or senile osteoporosis. Secondary osteoporosis occurs when other conditions or medications interfere with bone building or cause bone depletion. There are two main types of osteoporosis: primary and secondary. Many people have both primary and secondary osteoporosis. In addition, disuse osteoporosis occurs when a person is unable to move due to injury, bed rest, obesity, and microgravity-related bone loss in astronauts after space flights. Bone mass decrements occur when weight-bearing activities are not performed; muscles are not loaded sufficiently and do not react with ground force. Causes of secondary osteoporosis can include:
- Alcohol abuse
- Gastrointestinal disease
- Hypercalciuria (high levels of calcium in the urine)
- Chronic obstructive pulmonary disease
- Cystic fibrosis
- Anticonvulsant medications
Bone Life Cycle
Bone production begins in the womb or embryonically. Cells differentiate to form organs, tissues, and bones. Postembryonic development continues throughout adolescence. Cell differentiation in bone is when the cells take on certain characteristics and become osteoblasts. These cells form a matrix or architecture, and become osteocytes. The bone is then a spongy mass but not compact and hard. Connective tissue, the periosteum, makes new osteoblasts that cannot enter the spongy bone mass. Instead, the new cells form a hard and dense outer shell and the mass becomes a full-fledged bone. Bone cells continue to divide and multiply; bones become wider and longer until puberty is reached, when they stop growing.
After puberty, blood supply continues to feed the bone marrow, a jelly-like substance in the middle of the bone. The bone marrow makes new bone cells. Bone marrow also makes red and white blood cells, the minerals calcium and phosphorus, calcitonin, parathyroid hormone, estrogen in women, testosterone in men, and other hormones. 85% – 90% of bone mass is reached by the age of 18 or 20. Bones shed old cells and make new ones until about the age of 30. From that point, the bones work to conserve existing cells, rather than make new ones.
Bone strength is determined at puberty according to bone mineral density (BMD), size and shape, rate of old cell shedding, architecture and mineralization efficiency. Before puberty, bone grows rapidly in a short period. Males gain the most bone at a later age than females because males have a later onset of puberty. Those who experience early puberty may not benefit in the long term. The rate of adult bone loss is generally 1-2 percent per year. Gains in bone density prior to puberty can therefore correspond to 5, 10, or 20 years of bone density in later years.
Bone Remodeling Process
Osteoporosis develops due to an imbalance in the remodeling process when more bone is lost than is replaced. This complex physiological condition is due to a variety of factors. Researchers believe that more bone is lost than replaced due to genetics and protein activity. New theories implicate skeletal lipidomics, the regulation of bone metabolism, including fatty acids and amino acids. Interactions among various hormonal factors, cytokines and regulatory systems combine to lose bone cells and prohibit growth of new cells, leading to disequilibrium in bone remodeling.
How do you get Osteoporosis?
Fractures – any kind of fracture can occur with osteoporosis. Sometimes just a simple movement like bending over or picking something up may cause a bone break. Fractures often occur from a fall or a near fall.
- Hip – fracture of the upper thighbone occurs during a fall, a simple twisting motion or from a direct blow from the side or front of the thigh. Surgery is performed with plates and screws, and sometimes a total hip replacement is necessary. Most hip fracture patients are already of an advanced age and a hip fracture severely limits mobility and quality of life. Hip fractures often leave an individual unable to walk independently, which often leads to a necessity for nursing care or admittance to a nursing home.
- Wrist – two bones in the lower arm, the radius and ulna, plus the small bones of the hand are vulnerable to osteoporotic breaks. Wrists often break as the person uses their hand to break or cushion a fall.
- Spine – vertebral compression fractures are the most common fractures, however, 60-70 percent of spinal fractures go unnoticed. This type of fracture often leads to additional spinal fractures and the more devastating hip fractures.
- Death – disability and complications from surgery increases an individual’s chance of death, especially in the year following a hip fracture. The chance of early death is about 25 percent higher for hip fracture patients.
- Back pain – when a person over the age of 45 suddenly has back pain, physicians often suspect osteoporosis. Osteoporosis can cause back pain even in the absence of fractures.
- Loss of height – osteoporosis can cause the spine to either compress or curve (Kyphosis). People often become shorter as they age or develop a hump or deformity in the spine.
- Vertigo – patients with osteoporosis have been found to have vertigo three times more than the general population. Vertigo is an inner ear disorder and a common cause of dizziness. A problem with calcium metabolism after the age of 50 is thought to cause vertigo and osteoporosis.
- Heart failure – a causal relationship or a common denominator may exist between osteoporosis and heart conditions. Researchers have found that osteoprotegerin (OPG), a protein and cytokine receptor, is high in osteoporosis and atherosclerosis. Other studies have found that 12 percent of heart patients have undiagnosed spinal compression fractures.
- Abdominal obesity – visceral or intra-abdominal fat, located in the abdominal cavity, is associated with decreased bone mineral density.
- Alcohol – drinking alcohol regularly or binge drinking.
- Androgen deprivation treatment (in males).
- Anorexia nervosa – an eating disorder.
- Aromatase inhibitor treatment (in females).
- Caffeine – drinking coffee or other caffeinated beverages.
- Cushing syndrome – the adrenal glands produce too much cortisol hormone.
- Estrogen – low levels before or after menopause.
- European, Hispanic, or Asian ancestry.
- Gender – females are more likely to develop osteoporosis.
- High intake of vitamin A and sodium may increase the risk of osteoporosis.
- Hormone treatment for prostate cancer or breast cancer.
- Kidney failure
- Kidney stone disease
- Low body mass index – being very thin.
- Maternal history of fragility fracture/osteoporosis.
- Medications – use of corticosteroids, thyroid medications and diuretics, especially over a long term. Glucocorticoid-induced osteoporosis is caused by taking prednisone (Deltasone, Orasone), prednisolone (Prelone), dexamethasone (Decadron, Hexadrol), and cortisone (Cortone Acetate).
- Menopause – early onset of menopause.
- Menstrual periods – lack of menstruation (amenorrhea) for long periods of time.
- Menstruation – late onset of menstruation.
- Not getting enough calcium, vitamin D, vitamin A, vitamin K, and magnesium.
- Older age – after age 75, the risk is the same for men and women.
- Race – white women, especially those with a family history of osteoporosis, are more likely to develop osteoporosis than black women.
- Rheumatoid arthritis
- Sedentary lifestyle
- Thyroid or adrenal gland disease.
- Weight loss – sudden decrease in body of weight of more than 10 percent of total body weight.
Symptoms, occurring late in the disease (there are no symptoms in the early stages), include:
- Bone tenderness
- Fractures, spontaneous with little or no precipitating trauma.
- Loss of height
- Back pain
- Neck pain
- Stooped posture, called Kyphosis or “dowager’s hump.”
- Limited mobility as standing or walking may be difficult.
- Lying down relieves pain symptoms.
- Impaired vision
In the absence of symptoms or lacking evidence of fracture, diagnostic testing is based on historical risk factors. Most experts agree that women over the age of 65 should be screened for osteoporosis in 2-year increments. Women younger than 65 years of age, with common risk factors, can be screened as well. No recommendations are evident for advanced age individuals, for when screening should not be initiated or not be performed. Some organizations have recommended screening for everyone over the age of 50 years. However, no studies have been completed which prove that screening is influential for reducing fractures.
Screening intervals will depend on the baseline measurement at the initial screening test. Bone Mineral Density (BMD) tests compare bone mineral density to the bone density of a young adult. A BMD score of -2.0 (minus 2) may lead more readily to osteoporosis. BMD score of higher than -2.0 may not need screening again for 5 to 10 years. Doctors are encouraged to use the scores as a starting point, and factor in the risk factors and lifestyle of their patients to determine the frequency of screening.
Predicting incident fracture and identifying subjects at risk of fracture may be more reliable with a test for handgrip strength (HGS). HGS has an independent predictive power for fractures and may be better than BMD testing. Combining handgrip measures with BMD scores may increase sensitivity and reliability for diagnosing osteoporosis and predicting fractures.
The DXA, Dual Energy X-ray Absortiometry, is the first test to order. Scanning with DEXA is widely used to measure bone mineral density. The scanner directs X-ray energy into the bone. Higher bone mineral density will pick up more photons on the counter. Accuracy for predicting osteoporosis is estimated at about 90 percent. A score of greater than-2.5 (minus two point five) indicates osteoporosis.
Women should also have mammograms, pelvic exams, and Pap smears. Blood, urine and cardiovascular tests may be ordered if osteoporosis may be due to another medical condition. Other tests may include:
- X-rays of the spine, hip, wrist, and/or heel, spine.
- CT Scan
- Bone resorption
- Serum alkaline phosphatase, calcium, albumin, creatinine, phosphate, vitamin D, and protein electrophoresis.
- Thyroid function tests
- Urinary free cortisol
- Serum testosterone (men)
- Urine protein electrophoresis
Treatment goals for osteoporosis consist of slowing down or stopping bone loss. Osteoporosis, like many conditions, is managed by a physician or a multidisciplinary team of physicians or specialists.
Treatment strategies include:
- Pharmacological medications for both men and women are used to prevent and treat osteoporosis. Managing the order and timing of drug combinations is important.
- Existing fractures are allowed to mend and future falls or fractures prevented with medications and education in fall prevention. Bone breaks can cause significant disability and reduce the quality of life. Additional medications may be needed for pain relief from fractures.
- 3. Lifestyle changes consist of weight bearing exercise and optimum calcium and vitamin D intake.
Medications for Osteoporosis
Medications to maintain skeletal micro-architecture and minimize loss of bone mass mainly include bisphosphonates. However, depending on risk factors, male or female gender, lifestyle, adherence likelihood, tolerance and co-existing medical conditions and/or medications, other medications may be used. Medications and supplements commonly used for osteoporosis include:
- Bisphosphonates– alendronate, ibandronate, and risedronate are first-line medications for postmenopausal women and men. Alendronate (Fosamax), ibandronate (Boniva), and risedronate (Actonel) are taken orally, once a week or once a month. At times, bisphosphonates are given intravenously. Researchers have found that bisphosphonates are likely to confer a five-year survival advantage over those who do not take bisphosphonates.However, other studies have shown that bisphosphonates may increase the risk of other types of fractures, known as fatigue fractures. Patients taking bisphosphonates had a much greater incidence of fatigue fractures. Researchers caution that this result is negative for a small group of people and presents a small risk to the majority of osteoporosis patients. Bisphosphonates prevent many more fragility fractures than they cause, and all medications carry a risk of side effects.Physicians may recommend that patients stop taking bisphosphonates for a period of time or take a drug holiday after several years of taking bisphosphonates. Researchers have found that bisphosphonates continue to confer bone-stabilizing benefits for six months to three years of the drug holiday.
- Raloxifene (Evista) – a selective estrogen receptor modulator. The breast cancer drug Tamoxifen is similar to Raloxifene. Spinal fractures are reduced by fifty percent, but the drug does not show similar benefits for other sites of bone breaks, including the hip. Some studies show additional protective effects against breast cancer and heart disease. A small incidence of side effects exists for blood clots in the leg veins or lungs.
- Calcitonin – a medicine available in a nasal spray or injection. The drug slows bone loss and may relieve bone pain. Calcitonin is less effective than bisphosphonates. The nasal spray may irritate the nasal passage and the injection sometimes causes nausea.
- Teriparatide (Forteo) – a parathyroid hormone for severe osteoporosis. Daily shots are administered by the patient at home. Dizziness, fast heartbeat and muscle cramps are common side effects. A risk of cancer may be present for very high doses.
- Hormone Replacement Therapy (HRT) – rarely used to prevent osteoporosis. Estrogen is sometimes prescribed for women who cannot take other medications. HRT has a risk for serious side effects including breast cancer, blood clots, and heart disease.
- Testosterone – men do not experience the same rapid bone loss as women as they get older. Testosterone levels do not decrease dramatically. However, biologically active testosterone does decline with age. Downsides to testosterone treatment may include acne, weight gain, reduced HDL and increased plasma viscosity. Benefits include a decrease in blood pressure, serum triglycerides and total cholesterol. Delivery options include injections, implantations, a patch or transdermally through the skin, and orally.
- Calcium and vitamin D supplementation – calcium alone is ineffective without Vitamin D. Calcium and Vitamin D intake is an important part of dietary needs at every age. Bisphosphonates work seven times better if average circulating Vitamin D is 33 ng/ml and above, when tested during a blood screen.
Long Term Management
Physician use physiological tests known as biomarkers to diagnose osteoporosis. However, biomarkers are more commonly used to monitor the effects of pharmacological intervention. Bone turnover markers (BTMs) are used in clinical practice as they can show dramatic improvements in bone density. BTMs appeal to physicians in order to quantify treatment success and inform future decisions. Patients find BTMs useful in increasing their motivation to continue treatment. Biomarkers for bone formation (s-PINP) and bone resorption (s-CTX) are also used for their wide availability and ease of analysis.
Long-term management of treatment can be difficult as studies show that only 50% of patients take their medication after one year. Patients do not see immediate tangible results from the medication as they cannot see their bones getting stronger. Patients may underestimate their risks of not taking the drugs and overestimate the efficacy of lifestyle changes to improve osteoporosis. Many physicians support efforts to improve patient adherence.
How to Prevent Osteoporosis
Best efforts at prevention will happen before an individual reaches puberty. The age of puberty is important for both boys and girls, however boys reach puberty later. Dietary calcium and physical activity are also important factors in the development of bone mass. Pre-pubertal years are the best time for exercise and dietary calcium as the residual benefits will continue to prevent fracture in later life. Achieving adequate or peak bone mass continues into the 30s. After that, exercise, calcium and vitamin D are still critical efforts for a healthy body and mind. Taking extra vitamins, above the recommended levels, does not have extra benefits, for either children, adults or osteoporosis patients.
Regular exercise reduces the chances for a fragility fracture. Whether the exercise is performed as a child, a young adult or as an older individual with osteoporosis, weight-bearing exercise can help. Exercise is age appropriate and depends on motivation to perform. Socially structured activities or group activities may be the most helpful to increase motivation and adherence. Sedentary people and those with fracture rehabilitation should be encouraged to seek professional guidance before beginning an exercise program. Some common activities that may be enjoyable and confer bone building benefits:
- bike riding
- rowing machines
- lifting weights
- tai chi
A variety of vitamins, minerals, and other nutrients are important for health, especially bone health. Adults need about 1,000 mg. per day of calcium. Older people and osteoporosis patients may need more. Vitamin D is very important to improve the absorption of calcium. Adults are advised to get 600 IU per day of Vitamin D. Your physician may prescribe more or less depending on your dietary intake and sun exposure. Most fruits and vegetables have value to an individual’s diet; however, some foods have extra bone building benefits. For instance dried plums, or prunes, have an effect of suppressing the rate of bone resorption, the breaking down of bones. Tomatoes, especially after cooking, have lycopene, an antioxidant.
High-calcium foods include:
- Leafy green vegetables
- Low-fat milk
High Vitamin D foods include:
- Egg yolks
- Saltwater fish
- Fortified milk
Obese people, people with medical conditions, people on hypnotic drugs, people who do not exercise, patients with osteoporosis, and people with previous fractures have an increased risk of falling down. People diagnosed with osteoporosis are often given education in fall prevention. Physical therapy is often prescribed to increase strength and flexibility, especially in the hip region of the body. People are urged to wear proper shoes, have their vision checked and to avoid hypnotic drugs. Environmental changes can be made to reduce the likelihood of tripping in the house. Outdoor risks like walking on ice and snow can be avoided.
More Prevention Tips
Avoidance measures to retain bone mass include smoking and alcohol cessation. Counseling for these lifestyle behaviors may be useful. Limiting caffeine intake is often recommended for osteoporosis patients. Older people and those taking bisphosphonates may need more than two dental visits per year. Four yearly appointments may be needed to prevent gum disease, which rots the sockets that holds teeth in place. Sleep deprivation is associated with many metabolic disorders, including osteoporosis. Researchers have found that those who sleep less have lower BMD.
Researchers are still working to get around the estrogen problem. Estrogen depletion is responsible for postmenopausal osteoporosis. However, estrogen is associated with serious consequences and is rarely prescribed. Study efforts are focusing on harnessing the power of estrogen without complications. The estrogen receptor is the target of new possibilities. Side effects of blood clots and cancer may be outdated if researchers can use the estrogen receptors known as recipient molecules, that help the body react to estrogen. This type of work can lead to better targeting and successful treatment without side effects.
Screening and X-ray procedures are not proven to predict fracture risk. Screening is especially poor in predicting those with steroid-induced osteoporosis. A new method called the Raman spectroscopy, measures bone architecture by the reflection of light scattering off bone matrix. This non-invasive test can measure a bone’s structural integrity.
Patients do better when they have a dedicated clinic for diagnosis and treatment, according to one study. All-in-one medical facilities that diagnosed patients and prescribed medications on site rather than send them elsewhere for drugs, had better patient outcomes. Losing contact with the patient is avoided when the patient can get everything they need under one roof. Dedicated personnel, who are experienced in osteoporosis care, can identify, educate, test, diagnose, treat and follow up with patients in a more managed and effective way.
Own the Bone Campaign
In 2004, the US Surgeon General issued a position paper on Bone Health and Osteoporosis. The report specifically stated that physicians fail to treat osteoporosis when patients have a fragility fracture. Treatment for the underlying osteoporosis is only offered 20 percent of the time. This statistic is important considering that fragility fractures outnumber strokes, myocardial infarction, and breast cancer combined. In response, the American Orthopedic Association (AOA) launched a nationwide multidisciplinary project in 2009, called Own the Bone. The project uses a web-based registry to measure patient care in osteoporosis patients 50 years and older with fragility fractures. Registration was originally slated for hospital settings however, the program is growing and expanding to outpatient clinics and primary care physicians.
Bone Mineral Density (T-scores) are used to classify results from DXA, Dual Energy X-ray Absortiometry testing. The score indicates normal, a pre-osteoporotic condition called osteopenia, osteoporosis and severe osteoporosis. The T-score indicates the number of standard deviations above or below a normal, young adult BMD.
- Normal: T-score ≥-1 (minus one)
- Osteopenia: T-score <-1 but >-2.5 (less than minus one but greater than minus two point five)
- Osteoporosis: T-score of ≤-2.5 (minus two point five)
- Severe osteoporosis: T-score ≤-2.5 (minus two point five with the existence of fragility fractures)
Osteopenia is the stage before osteoporosis. It is caused by the same conditions as osteoporosis. The disease process can be delayed and treated with medication and lifestyle changes, and before fracture occurs.
A metabolic bone disease called osteomalacia is caused by deficits in mineralization of bone architecture. The matrix is incompletely mineralized. People with this condition have soft bones. The bones have enough collagen to give the bone structure but not enough minerals to make the bones hard. Vitamin D absorption may be hampered, which interferes with calcium absorption.
Symptoms of Osteomalacia include muscle pain and bone pain and sometimes a waddling or uneasy walking style. This condition may be genetic or due to environmental factors or events. Some gastrointestinal conditions or surgeries may prevent the GI tract from absorbing calcium or Vitamin D. Metabolic conditions or autoimmune deficiencies can also cause absorption problems. People who do not spend a lot of time in the sun or who wear sunscreen may be protected from sun damage and skin cancer, but also may not get enough Vitamin D. Osteomalacia is commonly found in those with illnesses or those who rarely leave the house. Even a few minutes of sun per day can create enough Vitamin D for most individuals. Treatment is found in treating the underlying medical condition, and/or by taking Vitamin D orally or by injection.
Osteoporosis is the most common degenerative bone disease. Porous, brittle bones can break at the slightest provocation. These fragility fractures impose a great risk for disability and decline in quality of life. Primary osteoporosis is most often an age related condition caused by a decline in sex hormones. Secondary osteoporosis is due to a medical condition or medication induced brittle bone disease.
Bone disease is highly prevalent around the world and growing in incidence as the population ages. Some countries can be expected to double their elderly population in the coming years. Age related diseases are also expected to increase. The incidence of osteoporotic fractures will increase with greater osteoporosis incidence. Hip and spine fractures are very serious, debilitating and often life threatening.
Screening for osteoporosis has proved ineffective in predicting those at high risk for fracture. Bone mineral density testing can, however, quantify the amount of healthy bone which nearly approximates the healthy bone of a young 30 year old person. Other types of testing including handgrip strength and infrared testing, which may prove useful in the future in predicting and preventing osteoporosis and fractures.
Treatment of osteoporosis is usually a combination of bisphosphonates, exercise, calcium and Vitamin D supplementation. Many patients, however, do not continue taking their medications after one year. Fall prevention is also a common treatment goal. Some foods may offer additional help beyond calcium and vitamin D. Plums may be able to stop bone depletion and tomatoes offer antioxidant benefits. Primary prevention consists of achieving peak bone mass before puberty, through proper diet and exercise.