World Osteoporosis Day

Cory Calendine, MD, Orthopaedic Surgeon

World Osteoporosis Day is celebrated on the 20th of October, worldwide and the aim is to raise awareness on the prevention, diagnosis and treatment of the disease that currently affects about millions around the world. Below is a summary video produced by the International Osteoporosis Foundation and links to additional resources on osteoporosis prevention and treatment.

ADDITIONAL RESOURCES FROM THE INTERNATIONAL OSTEOPOROSIS FOUNDATION:

• Osteoporosis Risk Check (Assess you risk of Osteoporosis and fracture by answering a few questions)
• 5 Essential Strategies for Bone Care (24-pg Osteroporosis Prevention and Treatment outline)
• Know Your Bones, Protect Your Future (16-pg Bone Health guide)
• Reduce Your Risk of Falls Guide

FRAX: ONLINE FRACTURE RISK ASSESSMENT TOOL – calculate your risk of fracture over the next 10 years.

What is Osteoporosis?

Osteoporosis is the most common bone disease. Osteoporosis is characterized by progressive bone loss that leads to brittle, thin and weak bones. The term osteoporosis (AH-stee-oh-por-OH-sis) literally means “porous bone”. In the United States, more than 53 million people either already have or are at high risk of developing osteoporosis. Half of all women and a quarter of all men over the age of 50 years will suffer a bone fracture caused by osteoporosis during their lifetime. Osteoporosis will contribute to an estimated 2 million bone fractures this year, and the National Osteoporosis Foundation estimates that number will increase to over 3 million by the year 2025. Osteoporosis is a disease that can be prevented and treated.

How does Osteoporosis develop?

Bone is living, growing tissue composed of a soft collagen framework that is strengthened and hardened by calcium and protein. Constantly through life, old bone is removed and new bone is added to our skeletons. During youth, new bone is added faster than old bone is removed producing stronger, heavier and more dense bones. Maximum bone density and strength is typically reached in our late 20s. After that time, bone resorption slowly begins to outpace the production of new bone. This process of bone thinning can progress gradually and painlessly for many years. If we do not take steps to keep our bones healthy, we can lose too much bone and develop osteoporosis. For many individuals, a broken bone is the first sign that they have osteoporosis.

What are the risk factors for Osteoporosis?

Age

The older you are, the greater your risk of osteoporosis (largely due to bone metabolism discussed above). Bones normally become thinner and weaker as we age with the risk of fracture increasing significantly after the age of 50 years.

Gender

Your chances of developing osteoporosis are greater if you are a woman. Women have smaller bones than men and lose bone faster than men partly due to hormone changes associated with menopause. For women, bone loss is fastest in the first few years after menopause and can continue with accelerated bone loss through postmenopausal years.

Ethnicity‍

White and Asian women are at highest risk for osteoporosis. African American and Hispanic women are at lower risk but face the same consequences. In fact, mortality after hip fracture is higher among African American women than most other ethnicities.

Family History (Heredity)

Having a close family member with osteoporosis or a history of fractures as an adult seems to increase your risk of reduced bone mass and fractures.

Poor Nutrition

Reduced dietary intake of Calcium and Vitamin D makes you more prone to thinning bones. Studies have established that low levels of Vitamin D and Calcium in the elderly are associated with increased risk osteoporosis, falls, fractures and reduced muscle mass and strength. Low body weight (being too thin – especially in women), makes you more likely to develop osteoporosis. Excess Vitamin A and high sodium intake are additional dietary risk factor for osteoporosis. Studies of caffeine intake and risk of osteoporosis have yielded conflicting results. Caffeine consumption has been reported to decrease bone density, increase the risk of hip fracture, and decrease calcium retention, so it is probably best to avoid excessive caffeine consumption.

Smoking

Smoking is bad for bones as well as the heart and lungs. Smoking cigarettes effects your body’s ability to properly utilize the calcium in your diet. Women smokers also typically go through menopause earlier, further increasing their risk for osteoporosis.

Alcohol  

Excessive consumption of alcohol increases the risk of bone loss and fractures. People who drink excessively are more likely to develop osteoporosis and suffer fractures from falls.

Inactivity

Periods of bedrest and limited activity will result in thinner, weaker bones. Like muscles, bones require activity and stimulation from regularexercise to remain strong. Even at younger ages, periods of inactivity increase your risk of osteoporosis.

Medications

Long-term use of certain medications, such as steroids and some seizure medications, can lead to loss of bone density and fractures. Steroids are often used in the treatment of arthritis, asthma, and other inflammatory diseases. It is important to discuss medication risks with your physician and pharmacist.

Other Illnesses

Many other chronic health conditions can impact your bone health. If you have one of the following health problems, speak to your doctor about your bone health and risk of osteoporosis: Anorexia nervosa, Asthma/allergies, Cancer, Cushing’s disease, Diabetes, Hyperparathyroidism,  Hyperthyroidism, Amenorrhea, Hypertension, Inflammatory bowel disease, Lactose intolerance, Lupus, Liver or kidney disease, Lung disease, Multiple sclerosis, Rheumatoid arthritis, Psoriasis

Osteoporosis Symptoms and Falls

Osteoporosis is often called a silent disease because bone loss can occur for decades without symptoms. As osteoporosis progresses, symptoms can include slump posture, loss of height, pain and fractures.

Height and Posture

As the spinal bones (vertebrae) weaken from osteoporosis, the front portion of the bones can compress and fracture, resulting in loss of height and curving forward of the spine. People who have lost at least 1.6 inches (4 centimeters) in height as they age should be evaluated for compression fractures in their spines caused by osteoporosis. This type of spinal fracture often initially causes no pain. As osteoporosis progresses, collapsed vertebrae become a frequent cause of back pain, loss of height and kyphosis (severely stooped posture).

Extremity Fractures

One in two women and one in four men older than 50 years will sustain bone fractures caused by osteoporosis during their lifetime. Bones that are weakened by Osteoporosis can fracture with minimal trauma including coughing, sneezing or performing basic household tasks. When osteoporosis is present, falls are often the cause of more severe bone fractures. Thinning bones and an increased risk of falls is a dangerous combination that comes with aging. One-third of people over 65 have a fall each year and many factors come together to further increase the risk of falling as we age.

In the elderly, falls often result in painful fractures of the arm, wrist, and leg and can seriously impact independence, lifestyle, activity and quality of life. Once one fracture has occurred, the chances of having additional fractures increases. This “domino-effect” of osteoporosis means patients who have suffered a fracture are more than four times more likely to have an additional fracture within the following year (compared to those that have never had an osteoporotic fracture).

A hip fracture is often the most serious and debilitating osteoporotic fracture. Most patients who experience a hip fracture and previously lived independently will require help from their family or additional in-home care. All patients who experience a hip fracture will require walking aids for several months, and many will permanently need a walker device to move around. With hip fractures, the mortality rate increases from 12 to 20 percent when compared to people of the same age and sex who have not sustained a fracture. Among people who survive surgical intervention for an osteoporotic hip fracture, only one-third are able to return to their previous physical abilities. This is why it’s important to optimize bone health and stop the falls before they happen.

How is Osteoporosis diagnosed?

Since osteoporosis often does not have many symptoms until a bone breaks, it is important to talk to your doctor about your bone health. Following a complete medical history and physical examination, if your doctor feels that you are at risk for osteoporosis, he or she may order skeletal x-rays, a bone mineral density (BMD) test, and/or additional laboratory tests. A bone density test measures how strong – or dense – your bones are and is the gold standard for diagnosing osteoporosis. Your physician will determine which type of bone density test is best for you. All bone mineral density (BMD) tests are quick, safe, and painless.

When to have a bone density test and how often to follow-up should be determined on an individual basis by your health care provider.  In general, all women aged 65 years or older should have a BMD test. Women who are younger than 65 years and past menopause should have a BMD test if they have had a bone fracture (because of fragile bones) or have other risk factors for osteoporosis, such as rheumatoid arthritis, smoking, alcoholism, a history of hip fracture in a parent, or low bodyweight.

How is Osteoporosis treated?

The results of a bone density test help your healthcare provider make recommendations about what you can do to reduce your chance of breaking a bone. When making a decision about treatment with an osteoporosis medicine, your healthcare provider will consider your risk factors for osteoporosis, your likelihood of breaking a bone in the future, your medical history and your current health.

Your doctor may want you to take medicine if your bone density test shows that your bones are weak and that you have a good chance of breaking a bone in the future. There are medicines to help prevent and treat osteoporosis. These include bisphosphonates; estrogen agonists/antagonists (also called selective estrogen receptor modulators or SERMs); calcitonin; parathyroid hormone; estrogen therapy; hormone therapy; and a recently approved RANK ligand (RANKL) inhibitor. In addition, a comprehensive osteoporosis treatment program always includes a focus on proper nutrition, exercise, and safety issues to prevent falls that may result in fractures.

What can I do to prevent Osteoporosis or keep it from getting worse?

Calcium and Vitamin D Rich Diet

Eat a well-balanced diet rich in calcium and vitamin D. Whatever your age or health status, you need calcium to keep your bones healthy. During the growing years, your body needs calcium to build strong bones and to create a supply of calcium reserves. Building bone mass when you are young is a good investment for your future. Inadequate calcium during growth can contribute to the development of osteoporosis later in life. As an adult calcium continues to be an essential nutrient because the body loses calcium every day. Although calcium cannot fully prevent the gradual bone loss after menopause, it continues to play an essential role in maintaining bone quality and strength. The National Academy of Sciences makes the following recommendations regarding daily intake of calcium:

• Males and females 9 to 18 years: 1,300 mg per day
• Women and men 19 to 50 years: 1,000mg per day
• Pregnant or nursing women up to age18: 1,300 mg per day
• Pregnant or nursing women 19 to 50years: 1,000 mg per day
• Men and women over 50: 1,200 mg per day

Excellent dietary sources of calcium include milk, cheese and other dairy foods; green leafy vegetables – such as curly kale, okra and spinach; fish where you eat the bones – such as sardines and pilchards; and calcium-fortified foods including cereals, bread and soya drinks. If your diet does not contain enough calcium, dietary supplements can help.

Vitamin D helps your body absorb calcium to build strong bones. Sunlight is the best natural source of Vitamin D. Your body produces Vitamin D when the sun shines directly on your skin. Just 10 to 15 minutes of sunlight without sunscreen a couple of times a week is usually sufficient to maintain normal vitamin D levels. Only a small proportion of vitamin D comes from the food we eat, but it is still important to include vitamin D rich foods in your diet. Foods that contain Vitamin D naturally include: fatty fish like salmon, tuna, and mackerel; beef liver, cheese, and egg yolks; and mushrooms have a small amount. Foods fortified with vitamin D in the US include milk, breakfast cereal, and some orange juice, yogurt, and soy drinks. It’s best to get vitamin D from sunlight and food, but you can also take it in a supplement. Always consult with your doctor before taking a calcium or vitamin supplement; too much can sometimes be toxic.

Exercise

Remember, bone is living tissue and, like muscles, exercise makes bones stronger. Optimal bone health relies on a lifelong commitment to daily exercise. Before menopause, exercise increases bone mass and it continues to slow bone loss after menopause. The Centers for Disease Control and Prevention recommend that healthy adults get at least 150 minutes of exercise a week (approximately 30 minutes or more a day through the week).

For healthy bones, include weight-bearing exercises in your routine. ‘Weight-bearing’ means activities that are performed while standing and that require your muscles and bones to work against gravity and resistance. Examples include walking, dancing, swimming and lifting weights. Non-weight-bearing exercises (Tai Chi, Yoga, and Pilates) are still beneficial and can improve balance, flexibility and posture to reduce your risk of falling. Bones, however, get the most benefit from exercises that require your muscles to work against resistance and weight, such as your own body weight, an exercise band, or handheld weights. Work with your health care provider, physical therapist or a certified trainer to incorporate more resistance exercises into your activity.

Lifestyle 

Don’t smoke. If you choose to drink alcohol, keep it to a minimum. Additionally, evidence argues toward avoiding excessive caffeine and salt intake.

Fall Prevention

Falls are the leading cause of fatal and non-fatal injuries for older Americans. Falls are costly—in dollars and in quality of life. However, falling is not an inevitable part of aging. Through practical lifestyle adjustments, evidence-based programs, and community support, the number of falls among seniors, and their debilitating consequences, can be reduced substantially. In addition to aging and osteoporosis, risk factors for increased falls include:

• Visual impairment
• Joint Pain or compromised mobility
• Blackouts or impaired cognition (Dementia)
• Impaired balance and muscle weakness
• Kyphosis (dowager’s hump, a severely rounded upper back)
• Slow walking speed
• Use of medications that cause dizziness and drowsiness
• Multiple drug therapies

Most falls can be prevented. You have the power to reduce your risk and protect your loved ones from a serious fall. Stay safe by following these tips from the National Council on Aging (NCOA):

1. Fall-proof your home – Floors: Remove objects you could trip over, such as throw rugs, electrical cords and clutter. Ensure mats are firmly affixed. Repair loose carpet or raised areas in the floor. Move furniture out of walking paths, and be aware of raised doorways; Bathrooms: Install handrails and non-skid mats in the toilet, bath and shower; Lighting: Keep your house well lighted, especially hallways, stairways, porches and outside walkways. Add extra light switches or use remote switches such as motion sensors. Add ceiling fixtures to rooms lit by lamps. Keep a flashlight with fresh batteries beside your bed; Kitchen: Use nonskid floor wax, and wipe up spills immediate. Keep regularly used kitchen items at an easy-to-reach level; Stairs: Check handrails are sturdy and secure. If using a step stool for hard-to-reach areas, use a sturdy one with a handrail and wide steps.
2. Avoid walking in socks, stockings, or slippers. Wear comfortable shoes with good support, a broad heel and non-slip (or rubber)soles.
3. Use a cane or walker for added stability.
4. Walk on grass when sidewalks are wet, slippery or icy.
5. Keep your glasses clean and in good repair. Use extra care on stairs if wearing bi-focals, and wear sunglasses on bright days to reduce glare.
6. Prescription medications can contribute to falling, particularly if you take three or more. Talk to your doctor if you feel dizzy, and ask about your medications. Use extra caution when changing or adjusting your usual medications.
7. Maintain a healthy diet that includes Vitamin D and calcium-rich foods
8. Do regular, suitable weight-bearing and muscle strengthening exercises, alongside exercises to improve balance and posture.
9. Maintain friendships and socialization to limit isolation and inactivity.
10. **Hip protectors: Studies have shown external hip protectors markedly decrease hip fractures in people when worn at the time of the event. These shells of propylene or polyethylene are designed to absorb part of the impact of falling and reduce hip fractures. However, there is poor compliance among people to wear them because they find them to be uncomfortable and impractical.

NCOA’s National Falls Prevention Resource Center supports the implementation of evidence-based falls prevention programs and serves as a national clearinghouse of tools and best practices. You can explore materials related to falls prevention in their Fall Prevention Resources Library. Falls Prevention Awareness Week, September 21-25, 2020, is designed to spread this important public health message.