DEFINITION: Throughout our life, a dynamic process is constantly occurring whereby bone is being broken down and rebuilt. This process occurs through an intricate interplay of a variety of hormonal, nutritional, and biochemical factors. The amount of bone broken down is generally balanced by an equal amount of bone that is made, so the total amount of bone mass does not change. When the amount of bone that is broken down exceeds the amount produced, a reduction in bone mass occurs, resulting in a thinning and weakening of the bones. This is referred to as Osteoporosis.

ETIOLOGY:

There are a number of causes of osteoporosis, but it is by far most commonly associated with advancing age. Osteoporosis can occur in both sexes, but it is more common in women. A slight decline in bone mass occurs in both sexes after age 40, but, in women, bone production is dependent upon estrogen, and as estrogen levels fall after menopause, bone production lessens markedly resulting in osteoporosis.

A number of medications can cause osteoporosis. Most common would be the corticosteroids such as prednisone. Osteoporosis can also be caused by:

-Lithium.

-Heparin.

-Anti-convulsants.

-Excessive Thyroid Medication.

-Some Chemotherapy Drugs.

A number of medical problems are also associated with an increased risk of osteoporosis. Many of these are uncommon to rare, but an increased risk is seen with some common medical problems such as diabetes, rheumatoid arthritis, and endometriosis.

RISK FACTORS FOR OSTEOPOROSIS:

The following characteristics are risk factors for the development of osteoporosis. The greater the number of risk factors, the higher the risk of osteoporosis.

1.)    Postmenopausal.

2.)    Family history of osteoporosis.

3.)    Short stature, slight build, small frame.

4.)    Asian or Caucasian.

5.)    Smoking.

6.)    More than moderate alcohol consumption.

7.)    Sedentary life style.

8.)    Lack of dietary calcium and magnesium.

9.)    Partial removal of the stomach or small bowel.

THE IMPACT OF OSTEOPOROSIS:

Osteoporosis is common. It is estimated that 13-18% of postmenopausal white women have osteoporosis (4-6 million women), and another 30-50% have low bone density (13-17 million women).

Osteoporosis exerts its major medical influence by leading to osteoporotic fractures. Current estimates indicate that 1 in 2 white women will experience an osteoporotic fracture in their lifetime. The most common sites of osteoporotic fractures are the hips, followed by the spine (vertebral fractures) and the wrist.

The occurrence of a fracture carries with it a significant amount of long term morbidity as well as mortality. 10-20% of women die within the first year after experiencing a hip fracture. 25% require long term care such as nursing home care or assisted living. Only one-third of women who experience an osteoporotic fracture fully regain their pre-fracture independence.

Fractures take their toll by leading to a variety of complications. Vertebral fractures can cause chronic back pain, and the postural changes and loss of height which result can lead to difficulty breathing by causing restrictive lung capacity. If fractures occur in the lumbar area they can alter the shape and volume of the abdominal cavity, leading to a variety of abdominal and intestinal problems such as poor bowel function, chronic constipation, esophageal reflux, early satiety, and difficulty sleeping due to heartburn. A variety of psychological symptoms can also occur, ranging from poor self-esteem from the postural changes, to anxiety and fear of sustaining a fall and another fracture. Depression is common due to the loss of independence, the limitations on mobility, and the activity limits imposed by these changes.

All of this carries with it, of course, a huge financial cost.

The risk factors listed above help determine who might be at risk for osteoporosis, so those women at risk can be identified and targeted for evaluation. To assist with decisions regarding diagnosis and treatment, the National Osteoporosis Foundation has put together a list of risk factors which address the risk not of developing osteoporosis but of experiencing a fracture.

The risk factors for experiencing a fracture include:

  1. History of a fracture as an adult.
  2. History of an osteoporotic fracture in a first-degree relative (mother or sib).
  3. Caucasian race
  4. Advanced age (usually considered 70 or older)
  5. Female.
  6. Dementia.
  7. Poor Health/Frailty.
  8. Cigarette Smoking.
  9. Early Menopause (below age 40).
  10. Low dietary calcium intake throughout life.
  11. Heavy alcohol use.
  12. Impaired eyesight (impaired even after correction, such as with cataracts).
  13. History of recurrent falls.
  14. Little/no physical activity.

DIAGNOSIS OF OSTEOPOROSIS:

The diagnostic procedure used to diagnose and evaluate the severity of osteoporosis is a measurement of bone density called a Bone Mineral Density analysis, or BMD. This is a type of scan or X-ray that determines the density of bone that is then reported using a number called a T-score. Based on this T-score, one’s bone density is placed into one of three categories:

1.)    Normal.

2.)    Low Bone Mass, also called osteopenia.

3.)    Osteoporosis.

The National Osteoporosis Foundation has established guidelines regarding who should undergo BMD testing. They would include:

  1. All women less than age 65 with one or more risk factors for osteoporosis (besides menopause).
  2. All women age 65 or older, regardless of risk factors.
  3. Postmenopausal women who have experienced a fracture.
  4. Women who are considering therapy for osteoporosis, if BMD testing would facilitate that decision.
  5. Women who have been on Hormone Replacement Therapy (HRT) for a prolonged period of time.

The purpose of BMD testing is to:

  1. Establish or confirm a diagnosis of osteoporosis.
  2. Monitor changes in bone density.
  3. Predict fracture risk.

THERAPY FOR OSTEOPOROSIS

TREATMENT VS. PREVENTION:

Therapy for osteoporosis falls into two different categories: Treatment and Prevention. Treatment would be for patients with established osteoporosis where the goal is to reverse the bone loss of osteoporosis and to prevent or retard its progression. Prevention would be for patients with essentially normal bone mass where the goal is to prevent or slow the development of osteoporosis.

The decision making process, then, addresses two questions:

  1. Is my therapy directed toward treatment or toward prevention?
  2. What does my therapy consist of?

CALCIUM AND VITAMIN D:

Calcium and Vitamin D are essential for the formation of new bone. Adequate amounts of Calcium and Vitamin D are the most important elements of any program for the treatment or prevention of osteoporosis. Calcium is directly deposited into the bone matrix in the formation of new bone, and Vitamin D is necessary for the absorption of calcium from the intestine. Both of these will be addressed below.

GENERAL RECOMMENDATONS FOR TREATMENT AND PREVENTION OF OSTEOPOROSIS:

There are several recommendations that can be given to everyone, regardless of whether the goal is osteoporosis treatment or prevention. These consist of:

  1. Lifestyle issues.
  2. Dietary issues.
  3. Dietary supplements.
  4. Medications.
  5. Reduction of the risk of fractures.

LIFESTYLE ISSUES:

  1. Exercise- Weight-bearing exercise stimulates the formation of new bone. Non-weight-bearing exercise such as swimming or cycling does not. The goal should be weight-bearing exercise three times per week. Daily is best.
  2. Smoking- Smoking cessation should be encouraged. Patients who are smoking at the time when osteoporosis therapy is considered have likely been smoking a number of years, perhaps a lifetime. So, a smoking cessation program, and possibly pharmacological treatment, should be considered for better success.
  3. Alcohol. Alcohol intake should be moderated so that intake is mild to moderate, which would be 1-2 alcohol-containing beverages per day.

DIETARY ISSUES:

Dietary choices, good and bad, can impact the development of osteoporosis. Some dietary factors have been implicated as possible causes of osteoporosis. These would include:

1.)    Diets low in calcium- Inadequate calcium intake would fail to provide the body sufficient amounts to form new bone.

2.)    Diets high in phosphates and protein- such diets have been shown to increase the elimination of calcium from the body by the kidneys, as measured by calcium excretion in the urine. Phosphates are present in large amounts in soft drinks, which should be avoided as part of and osteoporosis treatment and prevention program.

3.)    Diets high in sodium and refined sugars- Likewise, such diets have been shown to increase urinary excretion of calcium, making less available for the production of new bone.

4.)    Diets deficient in trace minerals- Studies have shown that magnesium and boron each play an indirect role in the formation of new bone. Magnesium is necessary for the conversion of Vitamin D to its active form. It is also involved in the regulation of the production of Calcitonin and Parathyroid Hormone, which regulate the formation of new bone. Boron is also necessary for the conversion of Vitamin D to its active form. It also reduces the excretion of calcium into the urine, and increases the amount of 17 beta-estradiol, the most biologically active estrogen, which will be discussed.

Dietary recommendations that would lessen and possibly prevent the development of osteoporosis would be:

1.)    Minimize dietary consumption of:

-Protein.

-Phosphates: such as in sodas

-Sodium: a reasonable limit would be 2000-2500 mg per day

-Refined sugar.

See our handout about nutrition and the Food Guide Pyramid for more details on following these recommendations.

2.)    Maximize dietary consumption of foods and beverages containing calcium.

Suggested daily calcium intake is 1000 mg per day before menopause and 1200 to 1500 mg per day after menopause.  Calcium can be found in milk and other dairy products. An 8-ounce glass of milk contains 300 mg of calcium. Calcium is also found in green leafy vegetables.

Calcium is also found in moderate amounts in oats and whole wheat

3.)    Maximize dietary consumption of green leafy vegetables. These vegetables are high in calcium, Vitamin K and boron. Vitamin K has been shown to have a role in the formation of new bone by converting into its active form a protein in the bone matrix to which calcium attaches. Green leafy vegetables high in calcium and Vitamin K include broccoli, cabbage, spinach, and lettuce. Green leafies high in calcium include asparagus and fresh green peas.

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DIETARY SUPPLEMENTS:

The role of the following dietary elements has been described above. The following are recommendation for supplementation to achieve adequate amounts of these substances:

CALCIUM:

Daily calcium intake should be 1000 mg per day before menopause and 1200 to 1500 mg per day after achieved through a combination of dietary sources and supplementation. Dietary calcium intake should be assessed, and the difference made up through supplementation. Calcium Citrate is preferred, as it is the most readily absorbed form of calcium supplementation. Calcium from oyster shells or bone meal should be avoided due a concern about unacceptable levels of lead.

VITAMIN D:

Vitamin D is produced in the body by the action of sunlight on the skin. The elderly, especially those in care facilities or those with limited mobility, may have little sun exposure, so supplementation is advised. Current recommendations call for supplementation with 400 IU/day. Many calcium supplements are formulated with appropriate amounts of Vitamin D included.

MAGNESIUM:

The role of magnesium in bone formation is known, but the science showing improvement with supplementation is scant. Dosing recommendations are for 400-800 mg per day.

BORON:

There is good evidence supporting the use of boron supplementation in osteoporosis treatment and prevention. Dietary sources of boron include the green leafy vegetables listed above, as well as legumes, nuts, and non-citrus fruits. Supplementation dose is 3-5 mg per day.

A HIGH-POTENCY MULTI-VITAMIN:

This is our advice for everyone looking to achieve improved health. We believe a multi-vitamin supplement is required to provide adequate amounts of vitamins and minerals required for proper enzyme function and metabolism.

MEDICATIONS:

As part of your osteoporosis therapy, it would be appropriate to evaluate any medications you are taking which are known to cause osteoporosis, to see if the dose can be lowered or perhaps stopped altogether. Those medications linked to osteoporosis are listed above.

REDUCTION OF FRACTURE RISK:

Looking at ways to reduce the risk of a fracture can help prevent the major complication of osteoporosis. This applies primarily to the elderly and those with impaired mobility, which would increase the risk of a fall. Such things would include:

1.)    Modifying the environment to reduce the risk of falls. Such as, placing things within reach so as to avoid the need for step stools, appropriate use of railings or other ambulatory aids, awareness of basic principles of walking safety such as caution on slick or steep surfaces.

2.)    Assuring optimal sensory capacity such as vision and hearing in order to maximize environmental cues that can affect safety.

3.)    Assessing dizziness or drowsiness as a side effect of medications, which can impact the risk for falls.

4.)    Looking for and treating orthostatic hypotension. This is the sudden drop in blood pressure encountered upon standing from a sitting or lying position, leading to dizziness and fainting. This is a common side effect of drugs commonly taken by the elderly, such as drugs to treat hypertension.

These recommendations should be followed by everyone whose goal is the treatment of osteoporosis and by those whose goal is prevention. For patients at low risk for developing osteoporosis, these recommendations may be sufficient. However, for patients at high risk of osteoporosis, and for those with existing osteoporosis, additional therapy should be considered. This therapy would include the available prescription medications for osteoporosis, as well as Complementary and Alternative therapies efficacy in osteoporosis therapy.

TREATMENT OF OSTEOPOROSIS:

Treatment of osteoporosis is intended to restore bone that has been lost, and to prevent further bone loss. The National Menopause Foundation has established guidelines regarding who should be considered for treatment. The guidelines use the results of BMD testing and risk factors for fracture to determine who should consider treatment. The T-score is the number given by the BMD test indicating bone density, and it is expressed as a minus figure to show how much bone has been lost. A T-score between 1 and 2.5 is referred to as low bone mass, or osteopenia, and a T-score less than 2.5 is osteoporosis. Based on these factors, the following women should consider treatment of osteoporosis:

1.)    Women with a T-score below 2, even if there are no risk factors for fracture.

2.)    Women with a T-score below 1.5 who have one or more risk factors for fracture.

3.)    Women over the age of 70 who have multiple risk factors for fracture. These patients are at a high enough risk for fracture that treatment could be considered without a BMD test.

Everyone who proceeds with treatment should follow the recommendations above regarding calcium, dietary issues, lifestyle issues, and nutritional supplementation. The next step in treatment would be to decide which medication to use to restore bone mass and prevent further loss.

PHARMACOLOGICAL TREATMENT:

There are four drugs approved by FDA currently available as therapy for osteoporosis:

1.)    Estrogen.

2.)    Raloxifene (Trade Name Evista).

3.)    Alendronate (Trade Name Fosamax).

4.)    Salmon Calcitonin (Trade Name Miacalcin).

The first three drugs are approved both for treatment and for prevention of osteoporosis. Miacalcin is approved only for treatment.

ESTROGEN:

Estrogen is the most effective drug for the treatment of osteoporosis, and would be considered the drug of first choice. Estrogen is also approved by the FDA for the prevention of osteoporosis. Estrogen can be taken by itself, referred to as Estrogen Replacement Therapy, or ERT, or it can be combined with progesterone, referred to as Hormone Replacement Therapy, or HRT. Women without a uterus can take estrogen alone, but women who have a uterus are advised to take estrogen along with progesterone to counteract the increased risk of uterine cancer associated with the use of estrogen alone. Combined estrogen and progesterone therapy can be taken either cyclically or continuously.

The decision to take estrogen should not be made solely on the basis of osteoporosis. Estrogen is also used to treat the problems of menopause. So, in addition to treating osteoporosis, estrogen therapy may also lead to the following benefits:

1.)    Improvement in hot flashes, vaginal dryness, mood swings, and other menopausal symptoms.

2.)    A reduction in genitourinary problems such as incontinence.

3.)     A reduced risk of cardiovascular disease by improving cholesterol, LDL, and HDL.

4.)    A reduce risk of dementia and Alzheimer’s Disease

As well, consideration of other factors may lead to the decision not to use estrogen. The following risks and side-effects may lead to the decision not to take estrogen, or to the decision to stop taking estrogen:

1.)    Vaginal Bleeding: This is one of the most troublesome side effects of estrogen. Attempts to manipulate the dose of estrogen and the way it is taken can be tried to control bleeding, but this remains for many women as one of the biggest drawbacks of ERT.

2.)    Other side effects: such as bloating, fluid retention, breast tenderness, and headaches.

3.)    Risks of estrogen: including an increased risk of blood clots and gall stones.

4.)    Risk of Breast Cancer: This is a topic in itself, but, in a nutshell, estrogen seems to moderately increase the risk of developing breast cancer. The degree of that risk depends on many factors, such as the way estrogen is taken, the duration of estrogen therapy, and whose numbers you want to believe. Of concern is the recent research showing an increased risk in women taken combined HRT, which was not previously known. It is now possible to determine your individual risk of developing breast cancer by using a mathematical formula known as the Gail Model Risk Assessment Tool. We can do this assessment for you at Nature’s Healthcare, if it has not been done. Determining your personal risk of breast cancer can assist you in your decision to take estrogen.

In summary, the decision to take estrogen should take into account the following things:

1.)    Your risk for osteoporosis, your risk for fractures, and possibly a BMD test.

2.)    The presence of menopausal symptoms.

3.)    The benefits of ERT as listed above.

4.)    The risks and side effects of ERT as listed above.

5.)    Your personal risk of breast cancer.

6.)    Your lipid status and your risk for heart disease.

For those patients who decide not to take estrogen, there are other drugs that can be considered.

FOSAMAX

Fosamax, or alendronate, would be considered the drug of choice after estrogen for both the prevention and the treatment of osteoporosis. Fosamax works by inhibiting the resorption of bone by the cells known as osteoclasts. While Fosamax works well for osteoporosis, it is not a hormone, and does not have any additional benefits such as estrogen for menopausal problems or heart disease.

Fosamax must be taken in a specific manner to facilitate its absorption by the intestine and to prevent it from causing side effects. This can prove to be bothersome for some patients. There are different doses recommended for treatment, the 10 mg dose, and for prevention, the 5 mg dose.

EVISTA

Evista, or raloxifene, is also approved for the treatment and prevention of osteoporosis. This drug is in a class of drugs known as SERMs, or Selective Estrogen Receptor Modulators. These drugs bind estrogen receptors and produce the effect of estrogen on that cell. It only does this, however, at certain estrogen-sensitive sites such as bone, but not at others, such as the uterus. In this way, one achieves benefit in osteoporosis without the increased risk of uterine cancer. Evista does seem to increase the risk of blood clots similar to estrogen, and it offers no benefit for symptoms of menopause. There seems to be, in fact, a slight increase in hot flashes with Evista as compared to placebo.

Evista has one shining feature that may make it the drug of choice for a sub-group of patients, which would be those women who are shown to be at a high risk of developing breast cancer by the Gail Model Risk Assessment Tool. For these women, there is one drug currently available and approved by the FDA which has been shown to lower their risk of developing breast cancer. That drug is Tamoxifen, which is also a SERM. However, Tamoxifen has no effect on osteoporosis, and carries with it an increased risk of uterine cancer. Preliminary studies show that Evista also reduces the risk of breast cancer, and it is felt that Evista will likely be approved as well for the prevention of breast cancer. Thus, for women with osteoporosis who are also at a high risk of developing breast cancer, Evista would be the perfect choice for their therapy.

MIACIN

Miacin is salmon calcitonin available as a basal spray. Calcitonin is a hormone that we produce that inhibits the resorption of bone. Miacin has been shown to be beneficial in the treatment of osteoporosis, but it is the least effective of the currently available drugs. Miacin is approved only for the treatment of osteoporosis, not for prevention.

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