Osteoporosis is a bone disease, the name of which means “porous bones” in Latin. The inside of a normal bone has small spaces, like a honeycomb. Osteoporosis increases the size of these spaces so that the bones lose strength and density. At the same time, the outside of the bone also grows weaker and thinner.
WHAT CAUSES OSTEOPOROSIS?
The biggest risk factor for osteoporosis is age. As people grow older, the body goes through the process of breaking down old bone and growing new bone in its place. Around the age of 30, however, the body starts losing bone faster than it is able to replace it. In women, going through menopause can cause the body to lose bone even more quickly for a period of time. Men continue to lose bone during this time, but at a slower rate. By the age of 65 to 70, women and men are usually losing bone at the same rate.
Osteoporosis results from a loss of bone mass (measured as bone density) and from a change in bone structure. Many factors will raise your risk of developing osteoporosis and breaking a bone. You can change some of these risk factors, but not others. Recognizing your risk factors is important so you can take steps to prevent this condition or treat it before it becomes worse.
Major risk factors that you cannot change include:
• Older age (starting in the mid-30s but more likely with advancing age)
• Non-Hispanic white or Asian ethnic background
• Small bone structure
• Family history of osteoporosis or an osteoporosis-related fracture in a parent or sibling
• Prior fracture due to a low-level injury, particularly after age 50
Risk factors that you may be able to change include:
• Low levels of sex hormone, mainly estrogen in women (e.g., menopause)
• The eating disorders anorexia nervosa and bulimia
• Cigarette smoking
• Alcohol abuse
• Low calcium and vitamin D, from low intake in your diet or inadequate absorption in your gut
• Sedentary (inactive) lifestyle or immobility
• Certain medications, including the following:
• glucocorticoid medications (also called corticosteroids), such as prednisone (brand names: Deltasone, Orasone, etc.) or prednisolone (Prelone); see fact sheet on glucocorticoid-induced osteoporosis
• excess thyroid hormone replacement in those taking medications for low thyroid or hypothyroidism
• heparin, a commonly-used blood thinner
• some treatments that deplete sex hormones, such as anastrozole (Arimidex) and letrozole (Femara) to treat breast cancer or leuprorelin (Lupron) to treat prostate cancer and other health problems
Diseases that can affect bones
• endocrine (hormone) diseases (hyperthyroidism, hyperparathyroidism, Cushing’s disease, etc.)
• inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, etc.)
What diseases or conditions may be linked to osteoporosis?
A risk factor is something that increases a person’s chances of developing a disease or condition. A number of factors can raise the probability of developing osteoporosis. They include:
The patient’s sex –
women are twice as likely to develop osteoporosis as men. Experts say there are two reasons for this: 1. Women start life with a lower bone life than men. 2. Women live longer than men. 3. The menopause causes a sudden drop in estrogen in women which speeds up bone loss.
Age –
a person’s bone mass lowers each year as he/she gets old. The falling bone mass continues until the person dies.
Vertigo –
Korean scientists found a link between people who suffer from vertigo and osteoporosis.
HIV –
people with HIV/AIDS have a significantly higher risk of developing osteoporosis, as this study found
.
Gastric cancer –
many surviving gastric cancer patients might suffer from osteoporosis and be at risk of developing multiple fractures in their later life, this article explains.
Ethnicity –
people who are Caucasian, or of South Asian descent are more likely to develop osteoporosis than people of African or North/South American Indian descent. However, the risk is still significant for everybody.
Family history –
people who have a close relative – parent or sibling) who has/had osteoporosis are much more likely to develop it themselves. This is especially the case if the close relative had fractures. A study found that a gene called DARC negatively regulates bone density in mice.
People with small frames –
people who have small body frames, as well as people who are very thin tend to have a higher risk of developing osteoporosis when they get older. This is because their bone mass is lower than other people’s when they start to age and bone density begins to fall.
Smoking –
people who smoke run a much higher risk of developing osteoporosis. Experts are not completely sure why.
Estrogen exposure –
women who have a late menopause, when estrogen levels drop significantly, have a lower risk of developing osteoporosis compared to women whose menopause arrives early or at an average age. Conversely, women whose menopause arrived early are at a higher risk.
Anorexia and/or bulimia –
people of both sexes who have, or have had eating disorders have a higher risk of developing osteoporosis. International Osteoporosis Foundation warns of bone damage from anorexia.
Cardiovascular disease and possibly Alzheimer’s disease link –
a research project at Rice University has brought scientists to the brink of comprehending a long-standing medical mystery that may link cardiovascular disease, osteoporosis and perhaps even Alzheimer’s disease.
Some medications:
Corticosteroids
– long term use of corticosteroids damages bones. Such drugs include prednisone, cortisone, prednisolone and dexamethasone. Patients with asthma, rheumatoid arthritis, andpsoriasis may have been prescribed these medications. Doctors often monitor such patient’s bone density and recommend other drugs to prevent bone loss.
Selective serotonin reuptake inhibitors (SSRIs)
– these are types of antidepressants. They have been found to lower bone density. It is not completely clear yet whether they do cause osteoporosis; but the fact that they have an impact on bone density means patients on SSRIs may need to be aware.
Blood thinning medications –
long term use may lower bone density.
Methotrexate –
a drug used for cancer treatment.
Some drugs used for epilepsy, diuretics, as well as some aluminum-containing antacids also cause bone loss.
Thyroid hormone –
if there is too much thyroid hormone in the person’s body his/her bone mass may be affected. This could be caused by an overactive thyroid (hyperthyroidism) or overconsumption of medications for the treatment of hypothyroidism (underactive thyroid).
Breast cancer –
women who have had breast cancer may have a higher risk of developing osteoporosis after the menopause. This is especially the case if they were treated with chemotherapy or aromatase inhibitors (anastrozole and letrozole) which suppress estrogen. Tamoxifen, on the other hand, reduces fracture risk and is not an osteoporosis risk factor.
Long-term low calcium consumption –
people who have consumed too little calcium during their lives are at a significantly higher risk of developing osteoporosis.
Some medical conditions and surgical procedures –
especially those which may undermine or lower calcium absorption. They include:
Gastrectomy (stomach surgery)
Crohn’s disease
Celiac disease
Vitamin D deficiency
Cushing’s disease
Long-term physical inactivity –
people who have lead a generally sedentary lifestyle with little exercise are much more prone to developing osteoporosis one day, compared to people who had physically active childhoods, and adulthoods
.
Too much caffeine consumption –
the association between high caffeine consumption and bone loss is highly suspected, but not completely proven. As caffeine is a diuretic it may increase mineral (calcium) loss. Many experts say that the phosphoric acid in sodas (fizzy drinks) may contribute to bone loss. People who drink lots of coffee and sodas should make sure they are consuming enough calcium and vitamin D.This study found that regular female cola drinkers have a higher risk of developing osteoporosis than women who don’t drink cola.
Alcoholism
– this is the main cause of osteoporosis among males. Consuming too much alcohol regularly undermines bone formation and messes with our body’s ability to absorb alcohol.
Depression –
people with depression tend to lose bone mass faster than other people.
How is osteoporosis diagnosed?
In most cases, the patient does not know he/she has osteoporosis until later on, when a bone is fractured. X-rays cannot measure bone density reliably – but they are good at identifying spinal fractures.
DEXA scan –
this scan measures bone density. DEXA stands for Dual Energy X-ray Absorptiometry. The DEXA scan measures bone densities and compares them to a normal range. The patient is then given a ‘T’score. This score describes the person’s bone density compared to the average. T scores are set out in the following way:
0 or minus 1 – normal range bone density
Minus 1 to minus 2.5 is a lower bone density. The patient has osteopenia (not osteoporosis)
Below minus 2.5 – the patient has osteoporosis.
The DEXA scan is fast, simple and accurate. It measures bone density in the most likely areas to be affected by osteoporosis – the spine, hip and wrist. It also follows changes in these bones over time.
Dental X-rays –
Researchers in the school of dentistry at the University of Manchester have created a unique way of identifying osteoporosis sufferers from ordinary dental X-rays.
Ultrasound –
an ultrasound scan can also provide a doctor with a reliable indication of bone density.
CT (computerized tomography) –
this can also provide a doctor with a reliable indication of bone density
.
Measuring calcium intake in men –
a study revealed that measuring a man’s daily calcium intake is an effective way of identifying prostate cancer patients with a higher than average risk of osteoporosis.
Who should have a test?
The National Osteoporosis Foundation says women should have a bone density test if they aren’t taking estrogen and:
Are aged 65 or over
Are postmenopausal and have one or more risk factors for osteoporosis
Have an abnormality in their spine
Are taking medications which may raise the risk of osteoporosis
Have Type 1 diabetes
Have a liver disease
Have a kidney disease
Have a thyroid disease
Have a family history of osteoporosis
Have experienced early menopause
Osteoporosis and bone growth
Bone is formed by specialised cells. Like the rest of the body, bone is constantly being broken down and renewed. It is living tissue that needs exercise to gain strength, just like muscle. In the early years of life, more bone is made than is broken down, resulting in bone growth. By the end of your teens, bone growth has been completed and ‘peak bone mass’ is achieved.
Sex hormones, such as oestrogen and testosterone, have a fundamental role in maintaining bone strength in men and women. The fall in oestrogen that occurs during menopause results in accelerated bone loss. During the first five years after menopause, the average woman loses up to 10 per cent of her total body bone mass.
Fractures of the spine caused by osteoporosis can lead to pain, loss of height and changes in posture, such as the ‘dowager’s hump’. This hump is caused when spinal fractures are compressed due to the force of gravity, resulting in an abnormal bending of the spine (kyphosis).
Risk factors for osteoporosis
There are many risk factors for osteoporosis, some of which you cannot change, such as being female, and having a direct relative who has had an osteoporotic fracture.
Other risk factors include:
• inadequate amounts of dietary calcium
• low vitamin D levels
• cigarette smoking
• alcohol intake of more than two standard drinks per day
• caffeine intake of more than three cups of tea, coffee or equivalent per day
• lack of physical activity
• early menopause (before the age of 45)
• loss of menstrual period if it is associated with reduced production of oestrogen, which is vital for healthy bones (the menstrual cycle can cease following excessive dieting and exercise)
• long-term use of medications such as corticosteroids for rheumatoid arthritis and asthma.
Some conditions place people at a higher risk of osteoporosis. These conditions include:
• thyroid disease or an overactive thyroid gland
• rheumatoid arthritis
• chronic liver and kidney disease
• conditions that affect the body’s ability to absorb nutrients, such as Crohn’s disease, coeliac disease and other inflammatory bowel conditions.
Prevention of osteoporosis
Both men and women can take steps from a young age to prevent osteoporosis by making sure that they:
• have a healthy and varied diet with plenty of fresh fruit, vegetables and whole grains
• Eat calcium-rich foods
• absorb enough vitamin D
• avoid smoking
• limit alcohol consumption
• limit caffeine
• do regular weight-bearing and strength-training activities.
Calcium-rich diet and osteoporosis
Enjoying a healthy, balanced diet, with a variety of foods and an adequate intake of calcium, is a vital step to building and maintaining strong, healthy bones. If there is not enough calcium in the blood, your body will take calcium from the bones. Making sure you have enough calcium in your diet is an important way to preserve your bone density.
It is recommended that the average Australian adult consumes 1,000 mg of calcium per day. Postmenopausal women and men aged over 70 years are recommended to have 1,300 mg of calcium per day. Children, depending on their age, will need up to 1,300 mg of calcium per day.
Dairy foods have the highest levels of calcium, but there are many other sources of calcium including sardines, spinach and almonds. If you are unable to get enough calcium from your diet alone, you might need to talk to your health professional about calcium supplements.
Vitamin D and osteoporosis
Vitamin D and calcium promote bone density. Vitamin D is important because it helps your body absorb the calcium in your diet. We obtain most of our vitamin D from the sun, and there are recommendations for the amount of safe sun exposure for sufficient vitamin D production, depending on your skin type, geographical location in Australia and the season.
Vitamin D can also be found in small quantities in foods such as:
• fatty fish (salmon, herring, mackerel)
• liver
• eggs
• fortified foods such as low-fat milks and margarine.
For most people, it is unlikely that adequate quantities of vitamin D will be obtained through diet alone. Talk with your health professional about vitamin D supplements if you are concerned that you are not getting enough vitamin D
.
Exercise to prevent osteoporosis
Weight-bearing exercise encourages bone density and improves balance so falls are reduced. It does not treat established osteoporosis. Consult your doctor before starting a new exercise program, especially if you have been sedentary, are over 75 years of age or have a medical condition.
General recommendations include:
• Choose weight-bearing activities such as brisk walking, jogging, tennis, netball or dance. While non-weight-bearing exercises, such as swimming and cycling, are excellent for other health benefits, they do not promote bone growth.
• Include some high-impact exercise into your routine, such as jumping and rope skipping. Consult your health professional – high-impact exercise may not be suitable if you have joint problems, another medical condition or are unfit.
• Strength training (or resistance training) is also an important exercise for bone health. It involves resistance being applied to a muscle to develop and maintain muscular strength, muscular endurance and muscle mass. Importantly for osteoporosis prevention and management, strength training can maintain, or even improve, bone mineral density. Be guided by a health or fitness professional (such as an exercise physiologist) who can recommend specific exercises and techniques.
• Activities that promote muscle strength, balance and coordination – such as tai chi, Pilates and gentle yoga – are also important, as they can help to prevent falls by improving your balance, muscle strength and posture.
• A mixture of weight-bearing and strength-training sessions throughout the week is ideal. Aim for 30 to 40 minutes, four to six times a week. Exercise for bone growth needs to be regular and have variety.
Lifestyle changes guard against osteoporosis
Be guided by your doctor, but general recommendations may include:
• Stop smoking – smokers have lower bone density than non-smokers.
• Get some sun – exposure of some skin to the sun needs to occur on most days of the week to allow enough vitamin D production.
• Drink alcohol in moderation – excessive alcohol consumption increases the risk of osteoporosis. Drink no more than two standard drinks per day and have at least two alcohol-free days per week.
• Limit caffeinated drinks – excessive caffeine can affect the amount of calcium that our body absorbs. Drink no more than two to three cups per day of cola, tea or coffee.
Management of osteoporosis
If you have osteoporosis, the strategies listed to prevent osteoporosis will help to manage the condition, but you may also need to consider:
• safer exercise options
• falls prevention
• medication.
Safer exercise options with osteoporosis
If you have osteoporosis, the risk of a fracture (break) with high-intensity exercise and poorly performed strength training can outweigh the bone-building benefits of these exercises. The best approach is to have an exercise program put together specifically for you by a physiotherapist or exercise physiologist.
The program may include:
• modified strength-training exercises
• weight-bearing exercise such as brisk walking
• gentle exercises that focus on posture and balance.
Falls prevention
A third of people aged over 65 fall every year and six per cent of those falls lead to a fracture. Reducing the risk of falls is important.
Be guided by your doctor, but general recommendations include:
• Perform exercises to improve your balance as prescribed by a physiotherapist or exercise physiologist.
• Wear your prescription glasses as directed by your optician.
• ‘Trip proof’ your home – for example, remove loose rugs, install handrails in the shower and toilet, and make sure all rooms are well lit. An occupational therapist can assist with this.
• Wear sturdy flat-heeled shoes that fit properly.
• Consider wearing a hip protector. This is a shield worn over the hip that is designed to spread the impact of a fall away from the hipbone and into the surrounding fat and muscle. Worn correctly, a hip protector can reduce the risk of hip fracture.
Treatment for osteoporosis
There is no standard treatment for osteoporosis. Treatment is tailored to your specific needs. Generally speaking, your overall risk of fracture helps to determine the best course of treatment.
Osteoporosis medications
As well as diet and lifestyle changes, your doctor may recommend medication. The options may include:
Bisphosphonates –
bone cells are created and broken down in a constant cycle. Bisphosphonates encourage bone density by slowing the ‘breakdown’ process. These medications are commonly used in Australia to treat osteoporosis in men and women.
• Selective oestrogen receptor modulators (SERMs) –
sites in the female body called ‘oestrogen receptors’ respond to the hormone oestrogen. SERMs mimic the action of oestrogen and therefore reduce bone loss. SERMs have been shown to reduce the risk of spinal fractures.
• Strontium ranelate –
similar to bisphosphonates, strontium ranelate slows down the ‘breakdown’ process of bones but also increases the ‘build-up’ process.
• Denosumab –
this is a twice yearly injection given under the skin. Denosumab slows the breakdown of bone.
• Testosterone therapy –
men with symptoms of testosterone deficiency and low testosterone levels can improve their bone density with testosterone replacement. Doses of testosterone are given by injections, implants, skin patches, oral capsules, gels or creams to bring the blood levels back up to normal.
• Parathyroid hormone –
the parathyroid glands make the parathyroid hormone (PTH). This chemical regulates the amounts of calcium, phosphorus and magnesium in the bones and blood. Parathyroid hormone therapy stimulates new bone formation and can increase bone density and strength. This medication is a daily injection used for people with severe osteoporosis when other types of medication are considered either unsuitable or ineffective.
• Hormone replacement therapy (HRT) –
in women, the female sex hormone oestrogen plays an important role in maintaining the strength of bone tissue. Menopause causes a marked drop in oestrogen levels, and increases the risk of osteoporosis and osteoporotic fractures. While HRT boosts oestrogen levels and prevents osteoporosis after menopause, it has also been associated with an increased risk of thrombosis (blood clots in the veins) and breast cancer. Its long-term use is no longer recommended for osteoporosis management.
It is important to note that all medications have potential side effects. If you are prescribed medications for osteoporosis, discuss this with your doctor. Treatment
Treatment for osteoporosis may involve:
• Lifestyle changes, such as diet and exercise
• Taking calcium and vitamin D
• Using medicines
Medicines are used to strengthen bones when:
• Osteoporosis has been diagnosed by a bone density study, whether or not you have a fracture.
• A bone fracture has occurred and a bone density test shows that you have thin bones, but not osteoporosis.
Medicines used to treat osteoporosis include:
• Bisphosphonates (the main drugs used to prevent and treat osteoporosis in postmenopausal women)
• Estrogens, teriparatide, raloxifene, and calcitonin
Exercise plays a key role in preserving bone density in older adults. Some of the exercises recommended to reduce your chance of a fracture include:
• Weight-bearing exercises — walking, jogging, playing tennis, dancing
• Free weights, weight machines, stretch bands
• Balance exercises — tai chi, yoga
• Rowing machines
Avoid any exercise that presents a risk of falling. Also, do not do high-impact exercises that can cause fractures in older adults.
Your body needs calcium and vitamin D to keep your bones strong. Vitamin D helps your body absorb calcium.
• Adults under age 50 should have 1,000 mg of calcium and 400 – 800 IU of vitamin D daily.
• Women ages 51 to 70 should have 1,200 mg of calcium and 400 – 800 IU of vitamin D a day; men ages 51 to 70 need 1,000 mg of calcium and 400 – 800 IU of vitamin D a day.
• Adults over age 70 should get 1,200 mg of calcium and 800 IU of vitamin D daily.
• Your doctor may recommend a calcium supplement.
• Follow a diet that provides the proper amount of calcium and vitamin D.
Stop unhealthy habits:
• Quit smoking, if you smoke.
• Limit your alcohol intake. Too much alcohol can damage your bones. This puts you at risk of falling and breaking a bone.
It is important to prevent falls. The following are suggestions on how to do this:
• Do not take sedating medicines, which can make you drowsy and unsteady. If you must take them, be extra careful when you are up and about. For example, hold on to countertops or sturdy furniture to avoid falling.
• Remove household hazards, such as throw rugs, to reduce the risk of falls.
• Leave lights on at night so you can see better when walking around your house.
• Install and use safety grab bars in the bathroom.
• Make sure your vision is good. Have your eyes checked once or twice a year by an eye doctor.
• Wear shoes that fit well and that have heels. This includes slippers. Slippers that do not have heels can cause you to trip and fall.
• Do not walk outdoors alone on icy days.
Surgery to treat severe, disabling pain from spinal fractures due to osteoporosis include:
• Kyphoplasty
• Spinal fusion
It’s never too late for osteoporosis treatment
If you have osteoporosis, it is never too late to seek treatment. Indeed, age is one of the main risk factors for osteoporosis and breaks. Treatment can halt bone loss and significantly reduce the risk of fractures.
It is important that your doctor excludes other medical conditions that can cause osteoporosis, including vitamin D deficiency.
Things to remember
• Diet, vitamin D and exercise can help to prevent osteoporosis.
• If you have osteoporosis, medical treatment can prevent further bone loss and reduce your risk of bone fractures.
• Treatment options for osteoporosis include dietary changes, exercise, lifestyle changes, falls prevention, supplements and medications.
