Osteoporosis: The Silent Epidemic

by Dr. Ronnie Nelson

1. WHAT IS OSTEOPOROSIS?
Osteoporosis simply means thin bones and is due to progressive loss of calcium and bone micro-structure from the skeleton, resulting in a weakening of the scaffold-like architecture within bones, until a point is reached where the bone will fracture if one sustains a fall e.g. fracture of the hip, or spontaneous vertebral fracture causing spinal deformity or loss of height, the 'little old lady' syndrome. The tragedy of the disease is that it may be totally asymptomatic until the first fracture occurs, which may have devastating consequences for the individual, including death, or debilitation and lifelong pain.

2. HIP AND SPINAL FRACTURE IN THE ELDERLY
The lifetime risk of an individual beyond the age of 75 years of sustaining fracture of the wrist, hip or vertebra is 40%. Andropause in men is also associated with osteoporosis with a slightly lower lifetime risk of fracture, which may be due to men having shorter lifespan than women. This means that many millions of people are at risk.

Studies suggest that almost 1 in 4 women and 1 in 9 men will experience a hip fracture in their lifetime in Sweden. Hip fractures account for more hospital bed days than heart attacks, breast cancer, diabetes or obstructive pulmonary disease among women aged 46 years or older in one study conducted in the U.K. The annual cost of the consequences osteoporosis in the USA is estimated at $1.3 billion and GBP500 millions in the U.K.

3. WHO IS AT RISK OF DEVELOPING OSTEOPOROSIS?
The main risk factors for developing osteoporosis are a family history of the disease, low body weight, early menopause (before 45 years), European or Asian ethnicity, and bilateral removal of the ovaries, advanced age. These are non-modifiable. The potentially modifiable risk factors are smoking, loss of periods in young women, low calcium intake, alcoholism, inadequate physical activity and incapacitating disease. Medication like excessive thyroxin, cortisone or heparin will also increase bone loss. In contrast excessive physical activity may also be detrimental especial in younger women athletes. These girls may have estrogen depletion as result of rigorous training and are as susceptible as their grandmothers of developing osteoporosis.

4. WHAT ABOUT THE DIAGNOSIS?
Standard X-rays show osteoporosis in an advanced stage and therefore have little place in early diagnosis. Two of the most useful means of detecting the early development of osteoporosis are ultrasound heel or wrist scans and a special type of x-ray scans called DEXA densitometry. DEXA scanning is the most accurate measurement of bone mineral density. This investigation is invaluable in both identifying which patients needs treatment and in the monitoring of therapeutic response. It is also able to diagnose osteopenia, a precursor to osteoporosis.

5. WE KNOW SO MUCH BUT WE DO SO LITTLE!
HORMONES: THE LONGER THE TREATMENT THE STRONGER THE BONES.
There is little question that the most cost effective way of preventing osteoporosis is hormonal replacement therapy (HRT) after the menopause. It is important to realize that estrogen in isolation is not as beneficial as when hormone are taken together with adequate calcium intake with vitamin D, regular exercise. HRT has the added benefit of lowering the incidence of colon cancer, complications of diabetes, heart attacks. Alzheimer's disease, dental problems, bladder and sexual dysfunction in the elderly. HRT is beneficial to osteoarthritis. For those women at risk of breast cancer or venous thrombosis or who choose not to take HRT, there are now established non-hormonal means of reversing osteoporosis and reducing fracture risk. Sadly, less than 20% of women continue with HRT beyond the first 2 years of menopause and very few men bother to treat their andropause.

HOW MUCH CALCIUM?
A diet high in calcium-rich foods such as dairy products, broccoli, and small sardine fish is essential to build strong bones during youth and up to the age of 25 years when "bone banking" takes place. Thereafter at least 80mg is the daily calcium requirement for adults. The elderly require double this (1500 mg) per days as their diets tend to be deficient in calcium and the bowel absorbs calcium less readily with advancing age.

Remember the adage: "CALCIUM AT NIGHT KEEPS THE BONES RIGHT' The reason for this that calcium needs lots of acid in the stomach to promote absorption and the most gastric acidity occurs after the evening meal.

OTHER TREATMENTS?
These are very effective non-hormonal therapies for osteoporosis for those women at risk of breast cancer or venous thrombosis or those who choose not to take HRT. These include: