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Osteoporosis - symptoms, treatment, prevention

 
Osteoporosis is a condition in which the density and quality of bones is reduced, making them weak, brittle and more likely to fracture. There are usually no symptoms of osteoporosis until a bone breaks.  Treatment and prevention will normally focus on lifestyle changes and medications to boost bone density. 
 
Osteoporosis is more common in  European and Asian New Zealanders but everyone will experience some loss of bone density as they age. It's estimated one in three women and one in five men aged 50 years or older will suffer a fracture due to osteoporosis.

General information 

Throughout life bone is constantly being broken down and renewed. At birth, bones are soft and harden as calcium and protein are deposited into them. Bone formation occurs rapidly in infancy, slowing down in childhood before massive bone formation occurs in adolescence. Adult levels of bone mass are reached by approximately 20 years of age with a small amount added until about 30 years of age. Adequate amounts of calcium are required for this ongoing bone formation to occur. Approximately 99% of the calcium in the body is contained in the bones and 1% is in the blood and body fluids.
 
Bone density refers to the amount of bone tissue in a certain volume of bone. It reaches its peak between 30 to 35 years of age and bone density decreases with age in both men and women. Many factors can alter bone density at any stage in life eg: genetic factors, race, gender, medical conditions and treatments, diet and lifestyle. Women lose bone density more quickly after menopause due to a decrease in oestrogen levels.  

Risk factors

There is no single cause of osteoporosis but there are many risk factors.  These include:  

  • Older age (>50 years)
  • Female gender
  • Thin build
  • Physical inactivity
  • Family history of osteoporosis
  • Smoking
  • Excessive alcohol or caffeine consumption
  • Low dietary calcium intake
  • Low levels of vitamin D
  • Long-term use of some medications eg: corticosteroids (such as prednisone and cortisone), thyroid medications, epilepsy medications
  • Deficiency of oestrogen in women eg: post-menopausal, irregular periods, surgical removal of the ovaries, early menopause (before the age of 40 years)
  • Deficiency is testosterone in men due to declining levels of testosterone with ageing
  • Treatments for prostate cancer that reduce testosterone levels in men and treatments for breast cancer that reduce oestrogen levels in women
  • Some medical conditions eg: endocrine diseases such as Cushing's syndrome and thyrotoxicosis; gastrointestinal diseases such as coeliac disease and Crohn's disease; rheumatoid diseases such as rheumatoid arthritis; and blood disorders such as multiple myeloma. 

Signs and symptoms

There are usually no symptoms of osteoporosis until a bone breaks. For this reason it is often referred to as a "silent disease". Fractures of the wrist, hip, spine, pelvis and upper arm are most common in osteoporosis. The fractures can be very painful and can lead to disability and loss of independence.

Over time there may be a gradual loss in height due to weakened and compressed vertebrae in the spine. Spinal fractures or crumbling of affected vertebral bones can lead to a Dowager’s Hump or Widow’s Hump. This results in an increasingly bent-over posture and may cause back pain.  

Diagnosis

A full medical history, including signs, symptoms and family history will be taken. If osteoporosis is suspected a specialised x-ray to measure the bone density is usually recommended.  
Bone density testing is usually undertaken using dual energy x-ray absorptiometry (DEXA). This is a specialised x-ray scanning technique that emits only very low levels of radiation (approximately 1% of the radiation required for a chest x-ray).
 
This precise and painless test takes about 20 minutes and requires the person to lie on a special table while the DEXA machine passes over them. The density of bone is measured at different locations (usually the lower spine and hip) and a formula is used to calculate the overall bone density. Individual bone density is graded by comparing it to the average bone density for a person of similar age, size and gender.  In some cases, bone density can also be measured using computerised tomography (CT scanning) or ultrasound scanning, though these methods tend to be less precise. 

Treatment

Treatment for osteoporosis will depend upon the results of bone density scans, age, gender, medical history and the severity of the condition.  Treatment most commonly involves lifestyle changes and medications and aims to maximise bone density and reduce the risk of bone fracture.

LIFESTYLE CHANGES

Exercise:
If possible, regular weight-bearing exercise (eg: walking, tennis, golf) should be maintained as it can help to reduce bone loss and stimulate new bone formation.  To be of benefit, doctors recommend at least 30 minutes of exercise at least three times a week.  Prior to beginning any new exercise it is important to consult a doctor to ensure that the proposed exercise is safe to undertake.
 
Diet:
As the body cannot make its own calcium, a diet high in calcium is necessary and helps to slow the rate of bone loss. Vitamin D is also essential as it promotes absorption of calcium into the bones. Eating a balanced diet that includes calcium and vitamin D-rich foods is important in supplying the bones with the calcium required.  Foods high in calcium include dairy products, dark green vegetables, beans, legumes, fish (especially sardines or salmon which are eaten with the bones), soybean products, cereals and nuts. It is recommended that at least 1000mg of calcium is taken in each day.  Foods high in vitamin D include sardines, tuna, eggs and liver.
 
Smoking, alcohol and caffeine:
Smokers will be advised to stop smoking. Minimizing alcohol and caffeine intake (eg: tea, coffee, cola drinks) may also be recommended.
 
Exposure to sunlight:
Regular but moderate exposure to sunlight helps to produce vitamin D in the body.  Note - excess sun exposure poses other health risks.
 
Reducing the risk of fractures:
It is important to take extra care with movement and daily activities in order to minimise the risk of fractures. This can include using mobility aids if unsteady on the feet, removing objects or hazards that can lead to falls (eg: loose floor rugs), installing hand rails in areas such as entranceways and bathrooms, and using non-slip mats in the bath or shower. Padding to protect vulnerable parts of the body eg: the hips, can also help in the prevention of fractures. Special "hip protectors" have been developed for this purpose. These can be enquired about at GP clinics and pharmacies.
 
MEDICATIONS
 
Calcium:
In general, calcium from the diet is preferred to calcium supplements.  However, if dietary intake of calcium is insufficient, calcium supplements may be prescribed in order to increase the amount of calcium available in the body. A dosage of 1000mg per day in usually recommended.  Note - too much calcium, especially in the form of supplements, has been associated with an increased risk of kidney stones and heart disease.
 
Vitamin D:
Vitamin D is important for the effective absorption of calcium into the bones.  Most people get adequate amounts of vitamin D from sunlight; however, for people who rarely go outside (eg, the frail elderly) or people who stay covered up when outside, vitamin D supplements may be beneficial.  Vitamin D supplements such as calciferol are usually given in conjunction with calcium supplements. An activated form of vitamin D called calcitriol has also been shown to be beneficial.
 
Bisphosphonates:
These non-hormonal medications can increase bone density by reducing the rate of bone loss. They have been shown to reduce the fracture rate in people with osteoporosis. These medications are usually given in an alternating cycle with calcium supplements. Common bisphosphonate medications used in the treatment of osteoporosis include alendronate (Fosamax) and zoledronic acid (Aclasta). A common side effect of these medications is nausea and indigestion. This can limit their use in some people.
 
HRT:
Hormone replacement therapy (HRT) medications that include oestrogen are sometimes recommended for women with osteoporosis. HRT has been shown to reduce bone loss and may increase bone density. While HRT has obvious benefits in the treatment and prevention of osteoporosis, research has indicated that there are risks with long-term HRT use including an increased risk of blood clots, endometrial cancer and breast cancer. It is therefore important that the patient and their practitioner discuss the benefits and risks of taking the medication.
 
Selective Oestrogen Receptor Modulators (SERMs):
This class of medications, also used in the treatment of some cancers, can be used to prvent and treat osteopporosis. A medication called raloxifene (Evista) is currently available as an osteoporosis treatment and has been shown to reduce the number of fractures in the spinal column. It works by mimicking the effects of oestrogen on bone, thus increasing bone density and may be considered for use with post menopausal women who cannot tolerate oestrogen.
 
Other medications
If the more common medications used to treat osteoporosis are not well tolerated or are not sufficiently effective, denosumab (Prolia) or teriparatide (Forteo) may be prescribed.
 
SURGICAL TREATMENT
 
Fractures are the main consequence of osteoporosis. Most tend to heal without the need for surgery. Sometimes, however, a fracture may be severe enough to require surgery to correct it.
 
Hip fractures - considered among the most serious types of fracture - are common in elderly people with osteoporosis. It is estimated that about 4000 people in New Zealand fracture a hip each year.

Prevention

Prevention is better than treatment and evidence suggests that maximising bone density in early and middle life helps to reduce the risk of osteoporosis in later life. Steps that can be taken to help prevent osteoporosis include: 

  • Stop smoking
  • Limit alcohol intake
  • Eat high calcium-containing foods
  • Undertake regular weight bearing exercise
  • Maintain a healthy body weight
  • Consider HRT for women during menopause
Having an adequate dietary calcium intake throughout life is also vital. In New Zealand the Ministry of Health recommends the following daily intake of calcium for healthy individuals:
 
 Children     9-13 years    1,000-1,300 mg
 Children   14-18 years    1,300 mg
 Men   19-70 years   1,000 mg
 Men   70+ years    1,300 mg
 Women   19-50 years   1,000 mg
 Women   50-70+ years    1,300 mg
                 
Note: the requirements for pregnancy and breastfeeding are not increased above the requirements for women who are not pregnant or breastfeeding.

Further information and support

For information or support contact a doctor, practice nurse, public health nurse or women’s health centre.  Information is also available from:
 
Osteoporosis New Zealand
Phone: (04) 499 4862
E-mail: info@osteoporosis.org.nz
Website: www.osteoporosis.org.nz

References

Mayo Clinic (2016). Osteoporosis (Web Page). Rochester, NY: Mayo Foundation for Medical Education and Research. http://www.mayoclinic.org/diseases-conditions/osteoporosis/home/ovc-20207808 [Accessed: 12/06/17]
National Health and Medical Research Council, Australian Government Department of Health and Ageing, New Zealand Ministry of Health (2017). Nutrient reference values for Australia and New Zealand including recommended dietary intakes (Guidelines). Canberra: Australian Government Department of Health and Ageing. https://www.nhmrc.gov.au/_files_nhmrc/file/publications/17122_nhmrc_nrv_update-dietary_intakes-web.pdf
Osteoporosis New Zealand (Date unknown). All about osteoporosis (Pamphlet). Wellington: Osteoporosis New Zealand. https://osteoporosis.org.nz/wp-content/uploads/OsteoNZ-DL-Brochure-WEB.pdf
Osteoporosis New Zealand (2017). Osteoporosis and fractures (Web Page). Wellington: Osteoporosis New Zealand. http://osteoporosis.org.nz/osteoporosis-fractures/what-is-osteoporosis/ [Accessed: 12/06/17]
 
Last Reviewed - June 2017

 

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