Osteoporosis: The Brittle Bone Disease

Online Course #9006 or #5006 - 10 Contact Hours
Author: Peggy M. Goulding, Ph.D.
Editor: Shelda L. Shank, RN, BSN, PHN
©2008 National Center of Continuing Education, Inc.

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Table of Contents …Review Part 1 …Independent Analysis …Evaluation

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Treatment and Prevention Strategies

The best treatment for osteoporosis is prevention. Once a fracture has occurred as a result of osteoporosis, it is effectively too late to implement the most effective treatment strategies. While some improvement in bone mass and quality has been demonstrated with aggressive treatment, the focus must be primarily on stopping or slowing any further bone loss. As noted above, alteration of lifestyle and patient education with regard to healthier choices are key to both prevention and successful treatment.

Diet tips for healthy bones

1. Eat plenty of foods high in calcium and Vitamin D. Good sources of easily absorbable calcium include broccoli, chestnuts, clams, dandelion greens, most dark green leafy vegetables, flounder, salmon, shrimp, whole grains, oats, beans, tofu, soybeans, and wheat germ.
2. Oxalic acid in certain foods binds with calcium in the intestine and prevents its absorption. Spinach, parsley, collard greens and beet greens, almonds, cashews, and asparagus are high in oxalic acid and calcium absorption from these sources is limited. Turnip greens, kale, and endive are high in calcium and low in oxalic acid.
3. Consume whole grains and calcium at different times. Bran cereals and unleavened whole-wheat products contain phytate, which binds calcium in the intestine and prevents its absorption.
4. Many Oriental foods contain high amounts of calcium, including sesame seeds, seaweed, miso, and soy products. However, they may also contain a great deal of sodium.
5. Alligator meat is an excellent source of calcium. (A bit difficult to catch but still good for you.)
6. At least three servings of a dairy food are necessary to give 1000 mg of calcium. Cottage cheese, yogurt and sliced cheese are good sources.
7. Tolerance to lactose can be increased by adding lactase tabs to milk 18 to 24 hours before drinking it. Yogurt is tolerated by those with a milk allergy since it's low in lactose.
8. Grated cheddar and Swiss cheese contain more calcium and less calories than Parmesan.
9. Use cottage cheese as a topper for bread instead of butter. Tofu also adds calcium to foods.
10. Include garlic and onions in the diet, as well as eggs. These foods contain sulfur, which is needed for healthy bones.
11. Marinating meat with the bone in it dissolves the bone and provides some calcium.
12. Fish bones (as in canned salmon, sardines) are rich sources of calcium.
13. Taking a calcium supplement with juice or food will provide acid to aid dissolution.
14. Oranges and papayas are high in calcium. Most other fruits aren't. Limit consumption of citrus fruits, as they may inhibit calcium intake.
15. Natural sweeteners, maple syrup and molasses contain a good deal of calcium, especially blackstrap molasses.
16. More calcium is contained in broccoli leaves than in the stalks.
17. If you can eat shrimp, shells and all, you will get more calcium.
18. High fat foods bind calcium in the intestine.
19. A diet high in red meat and other animal proteins prevents calcium absorption.
20. Avoid phosphate-containing products such as soft drinks, high-protein animal products, and alcohol. Also avoid sugar and salt.
21. Avoid yeast products. Yeast is also high in phosphorus, which competes with calcium for absorption.

Nutrition and Nutritional Supplements
Adequate nutrition influences all aspects of bone health throughout the life cycle, from the development of strong bones from childhood into early adulthood, to the maintenance of bone mass in adults, to the reduction of bone loss and fracture in the elderly. When it comes to your bones, you are what you eat and drink.

Calcium: Most Americans consume well below the US Recommended Dietary Allowance (RDA) of 1000 to 1500 mg of calcium per day, often because they avoid calcium-rich dairy products that they feel are too fattening. One expert estimates that teenaged girls probably consume less than one-half of the RDA for their age group. Adult women often continue the foolish practice of shunning dairy foods that started in their teens. During this period, they should be building bone mass to its peak levels but instead, they enter menopause far below their genetic potential, making their age and sex-related bone loss even more devastating. Bulimic and anorexic women compound the problem with their self-destructive habits, and their poor nutritional state and resulting amenorrhea take an early toll on their skeletons.
Little attention was paid to the calcium problem until recently. Two thirds of young American women aged 18 to 35,and 75% of the women over age 35, are consuming less than 800 mg of calcium per day. Calcium deficiency is common - more common than iron deficiency anemia. This can only lead to tomorrow's common disease - osteoporosis.
The National Institute of Health (NIH) Consensus Panel on Osteoporosis recommends the following calcium intake:

Recent studies have shown that those who have had a high lifelong daily intake of 1000 mg or more of calcium have a lower incidence of fractures than those who have taken less have. Researcher Robert Recker concludes that "higher calcium intakes do help preserve the skeleton of postmenopausal women and a total intake of 1.5 gm a day is adequate." Four 8-ounce glasses of milk will provide 1000 mg of calcium but, for many, supplements may be necessary. The average American diet without milk only provides 250 to 300 mg a day.
The effectiveness of calcium supplements in reducing peri-/post-menopausal bone loss remains controversial, perhaps because many of the research studies addressing this question failed to take into account the effects of estrogen withdrawal occurring at the same time. It appears that supplementation is most effective in reducing bone loss in women who are more than five years post-menopause, and in those who have long-term calcium intakes of less than 400 mg per day. Calcium supplementation appears to improve bone mass density, but the effect on reduction of fractures is currently less clear.

Phosphorus - Calcium Balance: The optimal ratio for building bones is one part calcium to one part phosphorus. Many people consume an excess of phosphorus because it occurs naturally in foods and is added to many processed foods, breads and drinks. Estimates of the individual daily consumption of phosphorus from these sources vary from 400 to 1800 mg. Laboratory animals when fed a diet high in phosphorus but low in calcium developed secondary hyperparathyroidism, which is associated with a loss of calcium and demineralization of bone. Phosphorus supplements are usually not recommended as there is an adequate amount in the diet.

Calcium Supplements: Since the dangers of osteoporosis were first publicized in the 1980s, the sales of calcium supplements have skyrocketed despite the lack of solid scientific support. So many drug companies have jumped on the bandwagon that it's impossible to open a women's magazine without confronting many full-page ads for calcium supplements. Packagers of calcium-enriched foods have joined the pharmaceutical companies, playing upon the fears of the public with advertisements of shrunken, little old ladies with bent spines. The sales of supplements have surged from $18 million to over $240 million annually; one distributor reported that sales of calcium have increased 40 percent, and are now his top selling product.
Consumers are confronted by a bewildering array of pills, tablets, liquids and powders loading the shelves of supermarkets, pharmacies and health food stores. Trying to pick the best brand and decide which dose is right could confound Einstein! For many, there is no right brand, only the right amount. For some, however, the type of calcium in the supplement does matter. A key characteristic of calcium is its solubility. Certain forms dissolve readily in water - something the body has plenty of. But insoluble calcium supplements require hydrochloric acid to dissolve before they can be absorbed. Elderly people frequently do not secrete a normal amount of acid. One gastroenterologist estimated that this is occurring in about 10 percent of the people over age 60 with the rate climbing to 30 percent among those 70 and over. People who have been treated for ulcers often have lower levels of gastric acid. Taking calcium supplements with food helps eliminate this problem, but experts advise anyone with impaired gastric acid secretion to use only soluble forms of calcium. Label readers know that calcium carbonate is the most common calcium supplement. They might recognize it in the familiar tablet of TUMS® or CHOOZ®. Yes, TUMS® spells relief - not only for acid indigestion but also for brittle bones! The only important difference between these antacids and the calcium carbonate supplement is the amount of calcium per tablet.
Calcium carbonate is usually the most inexpensive, concentrated source of calcium, containing 40 percent by weight. Sixteen TUMS® contain 800 mg calcium carbonate, of which 320 mg is pure calcium. It is available in a wide range of dosages, 140-600 mg per tablet, powder, gum coated, flavored or unflavored. Ironically, the one drawback is acid rebound: its neutralization of stomach acid later results in increased secretion. Taking calcium carbonate with meals eliminates this problem. Calcium carbonate has few other side effects and it enjoys the largest share of the market. The supplement is insoluble and requires hydrochloric acid to dissolve so it should be taken with food. Calcium citrate may be somewhat more easily absorbed than the carbonate; however, available preparations tend to be more expensive, and they contain relatively less calcium per dose.
There are three forms of calcium phosphate: mono, di and triphosphate. Only the first offers any degree of solubility and it is not usually in the supplements. Calcium phosphate is 23 to 39 percent calcium and rivals the carbonate compound as a source of the concentrated mineral. There are fewer complaints of gastric distress, and it is well suited as a calcium-fortifying food additive. Because Americans consume many phosphorus-containing colas and their diet is meat heavy, however, the average woman can easily consume four times as much phosphorus as calcium.
Chelates are one of the most expensive forms of calcium. They are basic supplements binding calcium to an amino acid, the building block of protein, rather than to a carbonate or phosphate. Manufacturers make unsubstantiated claims that this form is the most readily absorbed, but solubility varies as does the calcium content. Calcium chloride is available in granulated form and is not recommended because of the gastric irritation it causes. Its main use is in pickling foods and as a salt replacement for those who must avoid the most common salt substitute, potassium chloride. Calcium lactate and calcium gluconate are good choices for those who have an acid secretion problem, and they do not cause GI irritation or constipation. Their only drawback is a low calcium concentration: 13 percent in lactate and only 9 percent in the gluconate form. To receive an adequate amount of calcium, a great number of tablets would have to be taken, since most contain less than 100 mg each.
Powders of calcium gluconate, lactate, phosphate, or carbonate can be obtained in one-pound sizes. However, getting an adequate and accurate dose can be a problem. The cost is generally low, and the powder can be ordered by mail or from a health food store. A liquid, similar to calcium gluconate, called Neo-Calglucon, is available at pharmacies without a prescription. About two tablespoons contains 600 mg of calcium. This is an expensive way to get your daily calcium.
Dolomite contains about 20 percent calcium and is also a source of magnesium, but researchers have become concerned about recent discoveries of traces of toxic metals: cadmium, cobalt, lead, arsenic, barium, antimony, and aluminum. The Food and Drug Administration (FDA) found some samples contained concentrations of lead as high as 17 to 20 parts per million. They have advised that this supplement be avoided by pregnant or lactating women, and be used as little as possible for infants or young children. These same contaminants have been found in bone meal, another calcium source. Neither offers any particular advantage to those with a gastric secretion problem, and little scientific research has been done on them. Despite the popularity of dolomite and bone meal, experts recommend the use of other forms of calcium.
The most important information on the label is the amount of pure calcium. Many companies market calcium bound with another chemical, and not all are pure calcium. Some zealots become so enthusiastic that they are likely to consume far more than is beneficial. The NIH has stated that too much calcium can cause kidney stones in susceptible people who absorb calcium to abnormally high levels. This idiopathic hypercalciuria occurs when the kidneys try to excrete the calcium through the urine. Others develop stones regardless of how much calcium they consume. However, Dr. Robert Heany, a leading authority on osteoporosis, asserts, "Development of kidney stones in connection with high calcium intake is rare." Experts state an intake of 2000 mg daily should have little effect on stone formation. People who have a history of stones or an abnormally high level of calcium in the urine should consult a physician before starting any supplements.

Vitamin D: Vitamin D plays a crucial role in the regulation of calcium and phosphorus metabolism and promotes calcium absorption from the gut and kidney tubules. Vitamin D deficiency and insufficiency are important nutritional factors that require attention in all population groups, but especially in the elderly. The effects of the aging process on Vitamin D status is well documented (see above), and both the institutionalized and free-living elderly are at greater risk for deficiency due to their decreased activity level and exposure to the sun.
Supplementation with Vitamin D has been shown to improve calcium absorption, lower PTH levels, and reduce wintertime bone loss in post-menopausal women. A combination of Vitamin D and calcium supplementation has been shown to reduce fracture rates, but Vitamin D alone did not appear to be as effective.
Interestingly, a combination of Vitamin D and calcium supplementation has been shown to reduce the frequency of falls, as well as indices of body sway and blood pressure. This effect on factors associated with falling as well as falling itself has great potential for decreasing fracture risk.

Protein: Insufficient intakes of dietary protein have been implicated in the development of osteoporosis, and protein supplementation has been shown to improve the clinical outcomes of hip fractures. Lack of protein affects sex hormone status and synthesis of key growth factors. Very low protein intake has been associated with a decrease in bone formation and an increase in bone turnover, along with decreases in bone mass and overall bone strength.
Diets high in animal protein and poor in vegetable intake, however, are also implicated in the development of osteoporosis. Both animal protein and cereals are rich sources of phosphoric and sulfuric acid. On a Western diet, adults produce approximately 1 mEq of acid per day; 2 mEq of calcium are required to buffer this amount and prevent metabolic acidosis. Removal of this amount of calcium from the skeletal stores would result in a 15% loss of inorganic bone in an average individual in a decade. Of course, the more acid precursors consumed, the greater the degree of systemic acidity and the greater potential loss of bone. With increasing age, renal function declines and acidity increases; thus, humans become more acidic with age. Markers of meat intake, including zinc, magnesium, phosphorus, protein and fat, were statistically related to rapid bone loss in menopausal women. Women with a higher ratio of animal to vegetable protein intake had a higher rate of bone loss and a greater risk of hip fracture than did those with a low ratio of animal to vegetable protein intake.

Fruits and Vegetables: Recent population based studies have suggested a positive association between high levels of consumption of fruit and vegetables, with their high levels of potassium, magnesium, beta-carotene, fiber and Vitamin D, and bone mass and bone metabolism in women and elderly men. This may be due to the beneficial effects of the alkaline environment resulting from a diet rich in fruit and vegetables, and its ability to counter the effects of the acid-producing consumption of animal proteins and fats. Increasing one's fruit and vegetable intake from 3 to 9 servings a day may decrease urinary calcium excretion by as much as 30%.

Sodium. Modest salt restriction (5 grams daily) has been shown to reduce urinary calcium losses in the elderly, potentially resulting in a reduction in the loss of bone mass of around 1.5% per year.

Other Nutrients. As more study is done on the brittle bone disease, researchers are learning about other trace elements that appear to play a yet undefined role in bone health. Magnesium is a component of every body cell, vital to the enzyme system and important to nerve transmission. About half of the body's total supply is stored in the bones, and when osteoporosis depletes them, this mineral is also lost. Manganese, found in whole grains, nuts, some fruits, vegetables and soybeans, may prevent osteoporosis. A recent study of osteoporotic women found them to have extremely low levels of this trace metal, but the way it protects the bones has not been clearly explained. If a supplement is taken, it should not be taken with calcium since the two compete for absorption. Vitamin K appears to be needed for bone health, as several key bone proteins found in the bone matrix depend on Vitamin K for their synthesis. Significant circulating levels of menaquinone (Vitamin K2) have also been found in healthy elderly women and following osteoporotic fractures of the spine and hip. Vitamin B12 may have an important role as well. A study of osteoporosis patients found that a large proportion of those with low levels of this vitamin had suffered a fracture. There is also evidence that vitamin B12 suppresses osteoblastic activity.

Can Herbs Help?

Alfalfa, barley grass, black cohosh, boneset, dandelion root, nettle, parsley, pokeroot, rose hips, and yucca help to build strong bones. Caution: Do not use boneset on a daily basis for more than one week, as long-term use can lead to toxicity.

Feverfew is good for pain relief and acts as an anti-inflammatory. Caution: Do NOT use in pregnancy.

Horsetail and oat straw contain silica, which helps the body absorb calcium.

Alcohol, Tobacco and Caffeine
There is universal agreement that alcohol is a strong contributing factor to osteoporosis, but it's not known "how much is too much." A recent study of men who drank socially, one to two drinks per day, showed that they had a two-fold increase in risk of osteoporosis. It is known that alcoholism is the most common bone destroying disease in men under 60.Alcohol decreases the absorption of calcium in the intestine and has a negative effect upon the liver, which must help convert Vitamin D to its active form. Alcoholism is a notable cause of magnesium depletion that can result in concurrent hypocalcemia (low blood calcium levels). The exact mechanism is not yet defined, but this mineral deficiency will cause the blocking of calcium from the bones and also affect the secretion of PTH, which plays a role in bone building.
Cigarette smoking carries an increased risk of osteoporosis. Studies have shown that it results in lower estrogen levels, with menopause usually occurring about two years earlier in smokers. Smokers lose bone at a greater rate during the first years after menopause, and smoking is associated with a 40% to 50% increase in hip fracture. Nicotine constricts the blood vessels and this may impair bone nourishment as well as causing other diseases that affect bone health.
Add about five cups of coffee a day to those cigarettes and the risk of brittle bones is increased even more. Nutritionists tell us that caffeine encourages waste of calcium, with less being absorbed by the bones.

Exercise
Defining the role of physical activity in both the development and maintenance of bone health throughout the life cycle has taken on increased importance. As a key modifiable factor, exercise is important in both the attainment of peak bone mass and in the reduction of bone loss in later life. In fact, in the absence of weight bearing exercise, bone loss will occur at any age, at both axial (e.g., vertebrae) and appendicular (e.g., wrist and hip) skeletal sites. In a recent study examining bone loss in Russian cosmonauts, loss at the weight-bearing tibial site occurred within the first month in space and worsened with mission duration. In those cosmonauts that spent six months in space, losses ranged up to 23%.
Exercise regimens for post-menopausal women have shown a clear benefit on total bone mass, total bone density, and lean muscle area. Participants also showed significant improvements in psychological well being as well as functional fitness. It appears that, while normal levels of activity are sufficient to maintain bone health in pre-menopausal women, women who are estrogen depleted require greater amounts of mechanical force to preserve existing bone. It is encouraging to note, however, that low-strain physical exercise and rehabilitation programs can be beneficial to even very old women (aged 85 or more.) These exercise programs have the added benefit of improving overall muscle strength, which leads in turn to an improvement in balance and posture in the elderly population, thus lessening the risk of falls and fractures.
Regular exercise that puts mechanical stress on the bones increases their strength and retards loss in later years. The best exercises are those that require the spine and long bones to bear weight. Doctors at the Mayo Clinic studied a group of 68 postmenopausal women and proved a correlation between the strength of the extensor muscles of the back and the bone health of the vertebrae to which they were attached. To quote Dr. Mersheed Sinaki, "It seems that the muscles that are directly attached to the bones play the biggest role." She is now trying to determine whether strengthening back muscles can stop or reverse the loss of calcium from the vertebrae. Dr. Sinake points out that specific exercises are the most beneficial and recommends the extension exercises of arching the back and then straightening it. Women in this study who did the exercises showed 1/3 the spinal fractures of those doing no exercise or only bending ones. NIH has recommended three to four hours weekly of weight bearing exercise such as walking or jogging to increase bone density in those under 30 and slow bone loss in those who are older.
One word of caution, however: There is increasing concern for the bone health of women who engage in high-intensity physical training, for whom amenorrhea is a common condition. Many competitive women's sports also require extremely low body weights, and this combination can be very detrimental to bone health. Also, if bones are already weakened, any exercise program should be started with care and medical advice.

Prevention of Falls

Osteoporosis is a major health problem because it contributes to the risk for fractures and associated medical complications. Fractures are usually caused by falls, and fall prevention may be especially important for the person with osteoporosis. Many elders are aware of the complications of a serious fall, and this can lead to a fear of falling that saps one's confidence, lessens one's independence, and decreases one's activity level.
Here are some specific risk factors for falls, and ways to address them.

Poor Vision. Eyesight in general deteriorates with age, and vision may be further impaired by the development of cataracts, glaucoma, and macular degeneration. Vision may become blurred, and glare may become a problem. Older eyes often have difficulty adapting to significant changes in illumination, too. Changes in elevation, even slight ones like cracks in the sidewalk, can create a significant hazard. You can help an older person compensate for these vision problems by:

• keeping rooms lit brightly, but without glare
• removing throw rugs and other difficult to see obstacles, and creating clear paths from room to room
• increasing contrast on steps, between floor and carpet by use of white paint or tape
• reminding him to get regular eye exams and wear the correct prescription lenses

Limited Mobility. Age- and disease-related changes in gait, posture, and balance can contribute to falls. Muscle strength may be reduced, and arthritis may lead to decreased flexibility of the joints. Associated pain may further decrease activity level, leading to even greater losses of strength and flexibility. Age-related changes in the inner ear may affect balance. Older folks often lean forward as they walk, changing their center of gravity and making their stride shorter and slower. A shuffling gait may also add risk of tripping over unexpected hazards. The older person should:

• exercise regularly
• try to maintain participation in activities such as walking, gardening, and housework for as long as possible
• use a cane or other assistive device to improve balance (usually an unpopular alternative)
• consider the use of hip pads to reduce the risk of hip fracture (even less popular!)

Dementia. Persons with dementia, especially Alzheimer's disease, are generally at greater risk of falling than are other older adults. Safety awareness becomes limited, and the patient may lack insight into the consequences of potentially dangerous behaviors. Wandering is also common. While increased ambulation may provide much-needed exercise, it must be done in a safe, hazard-free environment. Restraints such as wheelchair seat belts and bed rails may prevent some falls, but attempts by the patient to circumvent them may lead to even more serious injury. The safest alternative for the patient with dementia may be close, consistent supervision.

Medications. - Prescribed and Otherwise. Drug reactions in the elderly may include dizziness, lethargy, weakness, impaired balance, and blurred vision, and all of these are major risk factors for falls. Sedatives and psychotropic drugs are the primary culprits, along with other hypnotics, tranquilizers and some hypertensive agents. Even diuretics and laxatives can contribute to falls, however, because they lead to more frequent trips to the bathroom; and the urgency of each trip may create additional likelihood of stumbling. Polypharmacy, especially with different prescribers, can compound the problem. Encourage the older person to:

• review all of their medications, prescribed and over the counter, with their primary health care provider on a regular basis, and report any of the above symptoms as soon as possible but especially after starting a new medication
• consider use of a bedside commode or protective bed pads or undergarments as needed 

Hormone Replacement Therapy
Hormone replacement therapy (HRT) has been used for many years in the treatment of osteoporosis but, despite its popularity, its efficacy in prevention of fractures is based more on opinion and anecdote than on clear scientific evidence. Estrogen replacement has even been recommended across the board for all menopausal women for prevention of osteoporosis. Until 1995, the benefits of HRT for reduction of osteoporotic fracture risk, as well as cardiovascular disease, were essentially unquestioned. However, recent findings that it is not as cardioprotective as previously assumed have again raised questions regarding its use for prevention of osteoporosis. The Women's Health Initiative, a large, multicenter, prospective trial of HRT, is currently underway to address the uncertainty surrounding the skeletal benefits associated with estrogen replacement. Until those results are available, HRT will undoubtedly remain controversial. The potential skeletal benefits of therapy must be weighed against concern about the increased risk of cancer of the breast, uterus or ovary.
Recent data do suggest that HRT, either estrogen alone or in combination with progestin, reduces the amount of bone loss in post-menopausal women. HRT has been shown to increase bone mineral density at various skeletal sites from 2% to 6%; results have been less positive in smokers and women with low body weight. Risk of fractures is also reduced, especially in women who begin estrogen replacement therapy within a few years of menopause. Some experts estimate that at least half of the fractures that occur as a result of osteoporosis can be prevented by HRT. Falls carry a potential death sentence for the elderly, and if the danger of cancer can be reduced by regular checkups, the benefits may outweigh the risks. Estimates have been made that estrogen replacement for five years after menopause will reduce a woman's chances of ever suffering a broken hip by 50 percent. Estrogen is most beneficial when bone loss is occurring rapidly - the first five to ten years after menopause or immediately after a total hysterectomy. The FDA has approved the drug for treatment or prevention of osteoporosis. If started at age 60 to 65, the hormone cannot repair lost bone tissue but it does slow further damage. If discontinued, bone destruction immediately resumes.
HRT is not generally recommended for women who have breast cancer, problems with phlebitis, unexplained vaginal bleeding, or for a woman with a close relative who has breast cancer. Those with fibrocystic disease should have their condition evaluated before starting treatment. The hormone may aggravate osteosclerosis; fibroid tumors; or porphyria, a rare disorder in which blood pigments accumulate in the body, causing severe headaches and abdominal pain. It is generally not recommended in the presence of gall bladder disease, diabetes or hypertension.
Some opponents of estrogen have suggested that a high intake of calcium plus a vigorous exercise program would suffice to reduce post-menopausal bone loss. However, studies have shown that even high levels of calcium intake do not substitute for estrogen. Treatment methods excluding estrogen have not been nearly as effective. Ultimately, the decision regarding use of HRT is one that must be made by each woman and her healthcare provider, based on her own circumstances and assessment of the relative risks and benefits to her overall health.

Antiresorptive Agents
A number of drugs have been identified that slow the progression of bone loss by suppressing the remodeling process. They reduce the depth of bone resorption (perhaps by reducing the life span of the osteoclasts) and may increase bone formation (perhaps by prolonging the life span of the osteoblasts.) Bone mineral density may increase due to more complete filling of the remodeling space and more complete mineralization of the existing bone. No new bone is made, however, so use of these substances is unlikely to replace bone already lost or change the existing bone's architecture or overall strength.

Bisphosphonates. These drugs are among the most thoroughly investigated in the field of osteoporosis. They offer an excellent alternative treatment for those post-menopausal women who cannot or choose not to use HRT. They also are the treatment of choice for individuals who are on high-dose steroid treatment resulting in significant risk for bone loss and fractures. They have been shown to prevent bone loss, increase bone mineral density, and reduce the risk of fracture of the spine, hip and forearm. The reduction in fracture risk is usually seen within the first 12 to 18 months of treatment. It is not clear, however, whether the risk reduction is comparable across all age groups, and whether or not it is sustained or lessens with time. Risedronate and alendronate are approved by the FDA for the prevention and treatment of postmenopausal and steroid-induced osteoporosis; etidronate is also a member of this class. An advantage of these drugs is that they are not hormones and have no significant effect on tissues other than bone.
The bisphosphonates are poorly absorbed, so should be taken on an empty stomach with plain water, at least 30 minutes before eating, drinking other liquids, or taking other medications. They have been reported to cause upper gastrointestinal irritation, and studies are underway to determine the relative safety of risedronate and alendronate. Esophageal irritation and other GI symptoms may be reduced by remaining upright after taking the medication. Once weekly dosing and other dosing schedules are being evaluated. Studies of patients who previously had reported intolerance to bisphosphonates found that most (about 85%) were able to continue when treatment was resumed, and permanent discontinuation rates were no higher than with placebo.

Selective Estrogen Receptor Modulators (SERMs). This class of drugs acts in different ways on the estrogen receptors of various organ systems. The first compound of this class that was shown to affect bone metabolism was tamoxifen, which prevented bone loss in post-menopausal women and appeared to prevent fractures in women treated with it for prevention of breast cancer. Although tamoxifen stimulates the endometrium, increasing the risk of endometrial cancer, its discovery spurred the search for a similar compound that would not cause cancer but retained its bone protective effects. One such compound is raloxifene, the most extensively studied SERM in the bone field today.
Both animal and human studies suggest that raloxifene reduces the rate of bone turnover, but to a lesser degree than estrogens or bisphosphonates do. When administered to post-menopausal but not osteoporotic women for two years, raloxifene increased bone mineral density and prevented bone loss at all skeletal sites; this effect was sustained for up to four years. It also reduced the risk of vertebral fractures in osteoporotic women with and without previous fractures. It did not, however, alter the risk of nonvertebral fractures.
Raloxifene increases the incidence of certain post-menopausal symptoms such as hot flashes, especially when give soon after the menopause. It may also decrease the incidence of breast cancer. Raloxifene does not stimulate the endometrium and thus should not increase risk for endometrial cancer.
Tibolone is, strictly speaking, not a SERM but shares some of the properties of the class. It is a synthetic steroidal compound with combined estrogenic, progestogenic, and androgenic properties that has been approved in some countries (but not the USA) for treatment of post-menopausal symptoms and prevention of osteoporosis. It appears to suppress bone turnover and increase bone mineral density to a degree similar to that achieved by HRT. This compound may present an option for the management of postmenopausal women, and appropriate clinical trials appear warranted.

Other Antiresorptive Agents: Calcitonin is a nasal spray preparation of the calcium-regulating hormone that may provide an alternative to HRT or bisphosphonates. It has been demonstrated to have only a modest effect on bone density and risk of vertebral fracture. In one study, its effects were indistinguishable from those of placebo over the first year of treatment. Further study is needed. Anticytokines are naturally occurring proteins synthesized by the osteoblasts that strongly inhibit osteoclast formation and activity by their action on certain bone proteins. A preliminary study showed that a single infusion of one of these substances suppressed bone resorption markers for up to a month, with no significant side effects or associated immunologic changes. Research is continuing on these substances. Ipriflavone is a plant flavonoid derivative with estrogenic activity that is marketed in Japan and a few European countries, and has recently been offered as a nutritional supplement in this country as well. It may have some effect on bone mass.
Patients on statin therapy for treatment of lipid disorders have been noted to have reduced risk for hip fracture, suggesting a possible role for these compounds in treatment of osteoporosis. They appear to stimulate bone formation and inhibit bone resorption, with a mechanism of action similar to that of the bisphosphonates. There is also some indirect evidence that NSAIDs may decrease bone turnover and be associated with greater bone mineral density. The effect seems to be related to their inhibition of COX-2 activity, and the recent availability of better tolerated COX-2-specific inhibitors may open a new area of investigation for the treatment of osteoporosis.

Parathyroid Hormone
There has been a recent flurry of interest in the use of parathyroid hormone (PTH) as an anabolic treatment for osteoporosis. Recent studies have shown that PTH reduces the risk of spinal fractures in post-menopausal women with and without previous fractures, and that this effect may be above and beyond that achieved by HRT in these same women. Fracture-related pain and mean height loss were also reduced. In contrast to the antiresorptive agents, PTH appears to be able to alter the architecture of existing bone and thereby increase its strength. Animal studies have shown that PTH is able to increase the thickness of both cortical and trabecular bone, and perhaps trabecular connectedness as well. The structural changes are accompanied by increased bone strength and seem to diminish after cessation of treatment; however, coadministration or later addition of antiresorptive agents to the treatment regimen may maintain the structural changes achieved by PTH.
Forteo, a parathyroid hormone-based medication manufactured by Eli Lilly and Co., recently won the unanimous endorsement of the U.S. FDA's advisory committee as a treatment for osteoporosis in postmenopausal women. The committee issued a 5-5 split vote on its recommendation as a treatment to increase bone mass in men with the disease. FDA approval is pending as of August 2001. The drug can only be administered by daily injections.

Long-term Compliance Issues

Long-term compliance with treatment for osteoporosis is a challenge for the clinician. B. Ettinger and his colleagues of the Kaiser Permanente Medical Care Program looked at the discontinuation rate among women initiating hormone replacement therapy (HRT), raloxifene, or alendronate after a BMD measurement. In more than 90% of cases, treatment was initiated because of concern about osteoporosis. The rate of discontinuation over 2 years was significantly higher for HRT (70%) than for raloxifene or alendronate (approximately 50%). Discontinuation appeared to be related to side effects of the treatment in 25% of cases with HRT, compared with 17% for alendronate or raloxifene. These results suggest that raloxifene and alendronate are less likely than HRT to induce a side effect leading to discontinuation. Even more important, this study shows the poor long-term compliance with osteoporosis treatment overall, a pattern that stresses the need for improving the awareness of the disease among patients and physicians.

Osteoporosis in Men

Although osteoporosis has generally been considered a disease of women, primarily because of its association with the physiological changes of menopause, men suffer from osteoporosis, too. Of the 10 million Americans who have osteoporosis, 2 million are men, and an additional 3.5 million men are at risk for development of the disease. Thus, osteoporosis in men is a significant but understudied problem.
Although men are less likely to fracture than women are, the lifetime risk of fracture in men is still 13% to 25%, with the same concomitant overall health risks. At age 50, the lifetime risk of hip fracture for men is about a third that of women, at 6% and 18% respectively, but the gap narrows considerably over subsequent decades. As in women, the risk of hip fracture in men is influenced by weight and physical activity: men who are overweight are 40% less likely, and those who are physically active are 16% less likely, to sustain a fracture. The majority of men with a diagnosis of osteoporosis will have a clearly identifiable cause: alcohol or tobacco abuse, a specific hormonal abnormality or other underlying disease, or secondary to corticosteroid or other medication use.
The incidence and risk of osteoporosis and fracture in men is less for a number of reasons. Men attain a higher peak bone mass during early adulthood, and their skeletons differ in dimension and strength as well. There is no dramatic hormonal change equivalent to a woman's menopause, although hormonal changes are implicated in the development of osteoporosis in men. Men have a shorter life expectancy, and they appear less likely to sustain a bone-fracturing fall. Interestingly, however, men are twice as likely to die during the year following hip fracture as are women.
After achieving peak bone mass, men generally maintain their bone mineral density (BMD) through middle age then lose it gradually, with an average lifetime decrease of approximately 40%. Like women, men tend to lose more trabecular bone than cortical bone, but the pattern of loss may be somewhat different. In women, the loss is due primarily to increased bone resorption, and results in diminished connectivity. In men, the loss appears to be due primarily to reduced bone formation; connectivity is maintained, with relatively less fracture risk as a result.
Many of the risk factors for development of osteoporosis are similar in men and women, including low dietary calcium and Vitamin D intake, diets high in animal protein and fat, smoking and alcohol use, slight thin build, and lack of physical activity. Overt hypogonadism in men has long been associated with low bone mass; bone loss results from hypogonadism in adults, whereas failure to achieve peak BMD is a consequence of hypogonadism of prepubertal onset. Beyond that fact, the specific relationship between hormone levels and osteoporosis in men is not clear. Testosterone appears to have a significant role in attainment and maintenance of BMD in men. Although there is no abrupt cessation of testicular function in healthy males, total and free testosterone levels may decline with age, or remain in the normal range throughout the life span. Relatively low correlations have been found, however, between testosterone levels and BMD in older men. It should be noted that androgens are partially converted to estrogens in older males, and higher correlations have been observed between estradiol (an endogenous estrogen) and BMD. The relative contribution of these hormones is still unknown, and both have been suggested to have a role in osteocyte apoptosis in both men and women. Recent treatment of prostate problems has included androgen deprivation: if this therapy proves to be successful, treated men may evidence an increased incidence of osteoporosis and fracture.
Genetic factors include higher overall risk in Caucasian and Japanese men, and may explain at least in part the 80% variance in peak BMD among young men. Familial factors such as maternal history of vertebral fracture have also been shown to contribute to osteoporosis in men. Genetic studies of the disease in men have focused on male hormone receptors and collagen genes.
Treatment of osteoporosis in men focuses on lifestyle modifications to prevent further bone loss and reduce fracture risk, treatment of disease-related pain, and various pharmacological approaches. Few drugs have been specifically approved for treatment of osteoporosis in men, but off-label use of those drugs indicated for women is not uncommon.
Clinical trials have shown that the bisphosphonates are generally effective in increasing BMD and lowering the risk of fracture among men with both idiopathic and corticosteroid-induced osteoporosis. Alendronate has been found to increase BMD at the hip and spine, and to decrease the risk of spine fracture; it has been approved by the FDA for treatment of steroid-related bone loss in men. New data suggest that alendronate is equally effective in men with low testosterone levels. Recent studies of risedronate have suggested that it, too, may be effective in reducing bone loss and preventing fractures. Several interesting studies have addressed the possibility of using SERMs to treat osteoporosis in men, given the apparent role of estradiol in bone health. Effects appear to be dependent on endogenous estradiol levels: the effects of raloxifene on biochemical markers of bone remodeling in men were determined by their circulating level of estrogen.

Future Impact of Osteoporosis

As our population continues to age, osteoporosis will have an even more profound impact upon the health of our nation. The economic consequences are enormous. Our rapidly expanding population is susceptible to this crippler and we should plan to care for 1.7 billion osteoporotic fractures by early in this century. Since everyone is in danger of developing the disease, steps must be taken now. Life-style and personal risk factors must be evaluated, and this becomes a highly personal process. What can YOU do to practice early prevention for yourself and your family? If the disease has already attacked your bones, what can be done to diminish the devastation? What can be done to delay its progression? For many, osteoporosis is a preventable disease, if they take action early. Just sitting back and waiting for the inevitable is foolish. Prevention of osteoporosis requires YOUR knowledge, YOUR participation and YOUR commitment.

PATIENT EDUCATION

Isn't osteoporosis something that happens only to older people?
No. Osteoporosis can begin when you are a child and is often not found until you are much older. That is why it is so important to eat well and get lots of exercise throughout your life to keep your bones healthy and strong.

What causes osteoporosis?
A family history of osteoporosis, the foods you eat, your hormone make-up, your age, and how you live your life all play a role in causing osteoporosis. The strength of your bones depends on their mass and density. And bone density depends in part on the amount of calcium, phosphorus and other minerals bones contain. When your bones contain fewer minerals, their strength is decreased and they lose their internal supporting structure. Scientists have yet to learn all the reasons this occurs, but the process involves how bone is made. Bone is continuously changing - new bone is made and old bone is broken down, a process called remodeling, or bone turnover. A full cycle of bone remodeling takes about 2 to 3 months. When you're young, your body makes new bone faster than it breaks down old bone, and your bone mass increases. You reach your peak bone mass in your mid-30s. After that, bone remodeling continues. But you lose slightly more than you gain - about 0.3 percent to 0.5 percent a year. Not getting enough vitamin D and calcium in your diet can accelerate the process.
Your risk of developing osteoporosis depends on how much bone mass you attained between ages 25 and 35 (peak bone mass) and how rapidly you lose it later. The higher your peak bone mass, the more bone you have "in the bank" and the less likely you'll be to develop osteoporosis as you lose bone during normal aging. Getting enough calcium and vitamin D in your diet, which is essential for absorbing calcium, and exercising regularly can help ensure that your bones stay strong throughout your life.

How do I find out if I have osteoporosis?
In the early stages of bone loss, you usually have no pain or symptoms. But once bones have been weakened by osteoporosis, you may have symptoms that include:

• Back pain
• Loss of height over time, with an accompanying stooped posture
• Fracture of the vertebrae, wrists, hips or other bones

Talk with your doctor to find out if you should be tested for osteoporosis. Doctors can detect early signs of osteoporosis with a simple, painless bone density test (densitometry). Until recently, the best screening test for osteoporosis was dual energy absorptiometry (DEXA or DXA).
In 1998 the Food and Drug Administration (FDA) approved a new device that can assess your risk for osteoporosis in less than 1 minute. The device, called the Sahara Clinical Bone Sonometer, transmits painless sound waves through the heel of your foot to measure your bone density. The denser your bone is, the healthier it is, and the longer it takes for sound waves to pass through it. The sonometer is a portable, inexpensive device that may make screening more accessible for everyone who's at risk for osteoporosis. Although the sonometer is accurate enough for screening, it's not currently as sensitive a diagnostic tool as DEXA.
If you're a woman, the National Osteoporosis Foundation recommends that you have a bone density test if you aren't taking estrogen and any of the following conditions apply to you:

• You use medications that can cause osteoporosis.
• You have type 1 diabetes (the type of diabetes that generally affects young people and requires treatment with the hormone insulin), liver disease, kidney disease or a family history of osteoporosis.
• You experienced early menopause.
• You're postmenopausal, older than age 50 and have at least one risk factor for osteoporosis.
• You're postmenopausal, older than age 65 and have never had a bone density test.

Doctors don't generally recommend osteoporosis screening for men because the disease is far less common in men than in women.

How is osteoporosis treated?
There are medications and hormones (chemicals that are made in your body) that are used to slow down the bone loss and even help build the strength of the bones back up. These treatments help keep your bones from breaking. Right now, hormone replacement therapy (HRT) is the best way to prevent osteoporosis in women. If you're considering HRT, you should know that estrogen therapy might cause side effects, including uterine bleeding and breast tenderness. There are treatments, however, that can reduce these effects. If you can't or don't want to take estrogen, other prescription drugs can help slow bone loss and may even increase bone density over time. Talk with your doctor to find out which treatments are best for you.

What can I do to help keep my bones healthy?
Here are some ways you can help keep your bones healthy.

• Get enough calcium. Calcium builds strong bones. You can get calcium by drinking lots of milk; eating yogurt, cheese, and other dairy products; and eating dark green and leafy vegetables. You also can eat foods that have calcium added to them such as orange juice and cereals. Many women take calcium pills to make sure they get enough calcium. Talk to your doctor about what is the right amount of calcium for you to get every day.
• Get exercise. Exercise is very important for good health and strong bones. Some of the best exercises for your bones are called weight-bearing exercises. Walking, running, dancing, climbing stairs, or using weights in a gym are all examples of weight-bearing exercise. Talk with your doctor about what kind and how much exercise is best for you.
• Don't smoke. People who smoke have more chance of getting osteoporosis.
• Don't drink lots of alcohol. Alcohol can hurt the cells that build your bones. It also lowers the amount of calcium in your body.
• Don't skip meals or go on fad diets. Skipping meals and going on fad diets can take away the foods your bones need to stay healthy.
• Talk to your doctor about hormone replacement therapy. Even before you go through menopause (the change of life), talk with your doctor about hormone replacement therapy. This is a treatment that puts hormones back in your body after your body stops making them. Hormone replacement therapy can help keep bone loss from taking place.
• Talk to your doctor to find out if you have more chance of getting osteoporosis than other people. Your doctor can help you find ways to keep your bones healthy and do tests to check the health of your bones. If you do get osteoporosis, your doctor can treat you with medicines and hormones.

What if I already have osteoporosis?
These suggestions may help you relieve symptoms and maintain your independence if you have osteoporosis:

• Maintain good posture. Good posture - which involves keeping your head held high, chin in, shoulders back, upper back flat and lower spine arched - helps you avoid stress on your spine. When you sit or drive, place a rolled towel in the small of your back. Don't lean over while reading or doing handwork. When lifting, bend at your knees, not your waist, and lift with your legs, keeping your upper back straight.
• Prevent falls. Wear low-heeled shoes with nonslip soles and check your house for electrical cords, throw rugs and slippery surfaces that might cause you to trip or fall.
• Manage pain. Discuss pain-management strategies with your doctor. Don't ignore chronic pain. Left untreated, it can limit your mobility and cause even more pain.

For More Information...

You can find out more about osteoporosis by contacting the National Women's Health Information Center (800-994-9662) or the following organizations:

National Osteoporosis Foundation
Phone: (202) 223-2226 or nof.org/
http://www.nof.org/

Osteoporosis and Related Bone Diseases National Resource Center
Phone: (202) 223-0344
(202) 466-4315 (TDD)
(800) 624-2663 (BONE)
http://www.osteo.org

National Institute on Aging
Phone: (800) 222-2225 (Information Center)
(800) 222-4225 (TTY)
http://www.nih.gov/nia

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