What is osteoporosis?

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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.

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.

The estimated national direct expenditure for hospital and nursing homes for fractures related to osteoporosis was $13.8 billion in 1995, or approximately $38 million per day. Florida’s average cost for treating a hip fracture caused by osteoporosis is $21,189 for hospitalizations alone. In 1996, 15,319 Floridians sustained hip fractures at an annual cost of $324,597,800, or $889,309 per day.

Today, approximately 10 million Americans have osteoporosis. Another 18 million Americans have low bone mass and are at risk for developing osteoporosis. Of these, 80% are women. This figure is estimated to rise to 41 million by the year 2015 unless steps are taken to educate individuals about prevention and screening.

In Florida, approximately 2.1 million citizens suffer from osteoporosis or low bone mass. This figure is estimated to climb to 3.5 million by the year 2015.

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.

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.

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. An average of 24% of hip fracture patients age 50 and over die in the year following their fracture.

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 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.

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.

How much calcium do I need and where do I get it?

The National Academy of Science’s Food and Nutrition Board revised the recommended daily intakes of calcium in 1997. The following intakes apply to both healthy individuals and those with osteoporosis:

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.

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.

What type of exercise is best for preventing osteoporosis?

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. Weight-bearing 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 does hormone replacement have to do with osteoporosis?

As a woman transitions into menopause, the point at which menstrual periods cease, the ovaries greatly decrease the amount of estrogen produced. At menopause, women face an increasing number of health risks related to estrogen loss, including osteoporosis. Many of these risks can be lowered by estrogen replacement therapy (ERT), which involves replacing the natural estrogen the body no longer makes.

In addition to reducing a woman’s risk for osteoporosis, there is evidence that estrogen replacement reduces the risk of cardiovascular disease in postmenopausal women with no previous history of heart disease and may help delay the onset of Alzheimer’s disease. Estrogen may also reduce the risk of colon cancer and age-related macular degeneration.

ERT may not be appropriate for everyone. It is not generally recommended for women with a history of breast or endometrial cancer, a history of blood clots to the lungs or active liver disease. There is also some indication that estrogen replacement may slightly increase the risk of breast cancer, although studies conducted to-date are contradictory on this point. Unless contraindicated, the decision to take estrogen therapy is largely a personal one and should be discussed with a health care professional.

What if I don’t want to take estrogen or my health care professional recommends that I not take it?

For women who cannot or choose not to take estrogen, there are two other medications recently approved for the prevention of osteoporosis. These are alendronate, sold as Fosamax, and raloxifene, sold as Evista.

Raloxifene is known as a selective estrogen receptor modulator (SERM). SERMS bind to estrogen receptors and produce estrogen-like effects in some tissues and estrogen-blocking effects in others. In bone tissue, raloxifene acts similar to estrogen and prevents bone loss. There are some indications that it may reduce the risk of cardiovascular disease as well, since it does lower cholesterol levels, but this has yet to be demonstrated in clinical trials. It does not appear to increase the risk of breast cancer, a possible concern with estrogen. Raloxifene is used for the prevention of osteoporosis only.

Is there a treatment for osteoporosis?

Estrogen replacement therapy, as discussed under the Prevention section, can be used to treat osteoporosis as well as prevent it. ERT helps maintain bone density in women with osteoporosis and can reduce the number of spinal and hip fractures by 50%. As mentioned, ERT is not appropriate for all women.

Alendronate can also be used to treat osteoporosis. Alendronate, one of a class of drugs known as bisphosphonates, suppresses bone turnover and reduces the frequency of fractures. It is well tolerated in general, although upper gastrointestinal side effects may occur. Proper dosing and avoiding use in patients with esophageal dysfunction or who are bedridden can minimize the frequency of these side effects. Alendronate is an effective alternative for patients in whom estrogen is contraindicated.

A third option is calcitonin, a naturally occurring hormone involved in calcium regulation and bone metabolism. Calcitonin works by slowing bone removal and preventing further bone loss. Because calcitonin is rapidly destroyed in the gastric environment, intravenous administration was previously the only dosing route. Recently, an easy-to-use calcitonin nasal spray has been developed.

How is osteoporosis diagnosed?

Osteoporosis was once diagnosed only after fractures had occurred because there was no test that could determine when bone had weakened. Since then, researchers have discovered that the most effective way to diagnose osteoporosis is through the use of bone mineral density measurements that can identify mineral loss in intact bone. Several technologies for measuring bone mineral density have been developed in the past, but most of these methods are not in use today.

The most reliable and practical method for measuring bone mass today is the dual-energy x-ray absorptiometry, or DXA, scan. DXA can compute the density of bone with great speed and accuracy, and a small radiation dose. DXA usually measures bone density at the hip and spine. The procedure takes approximately 10-15 minutes, during which time the patient lies on a table while an imager passes over the body. A computer calculates the density of the patient’s bones in grams per square centimeter and compares it to a standard for normal bone at peak bone mass and to the average bone density of individuals the patient’s own age. Bone with normal mineralization will produce a higher reading in grams per centimeter than osteoporotic bone. The cost for a DXA scan averages between $100-$200, but may be higher depending on the facility where the scan is performed. For information on insurance coverage, see the section titled "Will my insurance cover a bone density test?"

A modification of the DXA, called peripheral dual-energy x-ray absorptiometry, or pDXA, measures bone density in the wrist. The procedure is performed with a scanner the size of a desktop computer in about 5 minutes. A more recently developed radiation-free technique is quantitative ultrasound which measures bone density of the calcaneus (heel) bone. According to early studies, both these techniques appear to be reasonable predictors of overall bone density, but are not considered as reliable as DXA.

How does the bone density test define osteoporosis?

A diagnosis of osteoporosis is defined in terms of standard deviations from the average peak bone mass. The World Health Organization defines osteoporosis as a bone mineral density 2.5 standard deviations below that of a normal healthy 30 year old. Those who are between 1 and 2.5 standard deviations below the norm are defined as having osteopenia or low bone mass. Individuals within one standard deviation of the 30-year-old norm are considered to be at low risk for osteoporotic fracture.

Who should have a bone density test?

Recent guidelines issued by the National Osteoporosis Foundation recommend bone mineral density testing for the following individuals:

• Women 65 and older, regardless of other risk factors

• Postmenopausal women with one or more risk factor for osteoporosis (other than menopause)

• All postmenopausal women with fractures.

Will my insurance cover a bone density test?

The federal 1997 Balanced Budget Act passed by Congress includes a provision that outlines how Medicare is to cover densitometry testing. Uniform coverage of bone mass measurements under Medicare Part B went into effect July 1, 1998. Previously, interpretation of guidelines on this subject was left up to the individual carriers. The Act authorizes coverage for testing for individuals who fall into the following categories:

• women who are estrogen-deficient
• individuals receiving long-term glucocorticoid therapy
• individuals with primary hyperparathyroidism.
• Individuals being treated for osteoporosis
• Individuals with previous spinal fractures

These benefits apply to all Medicare plans, including managed care plans. Medicare will cover a bone density test every two years, but only if ordered by a treating health care professional.

In 1996, the Florida Legislature passed statutes requiring all individual health insurance policies (F.S. 627.6409), group insurance policies (F.S. 627.6691) and health maintenance contracts (F.S. 641.31) issued, amended or renewed after October 1, 1996 to provide coverage for osteoporosis screening, diagnosis, treatment and management for those individuals specified in the 1997 Balanced Budget Act and for those with a family history of osteoporosis. State employee health insurance programs were excluded from this requirement.

Is there anything else I can do if I have osteoporosis?

In addition to taking medication as prescribed by your health care professional, you should continue to follow the guidelines for prevention of osteoporosis, including getting adequate calcium, vitamin D and exercise and limiting alcohol, caffeine and smoking.

( Courtesy: www.doh.state.fl.us )