Osteoporosis

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There are three periods that are critical for prevention of osteoporosis—and prevention is key since there is no cure:

  • From the time of adolescence to age 25 (when peak bone mass is obtained). During this time, it is of critical importance to get lots of weight-bearing exercise, take calcium, and don't smoke.
  • At menopause, when women may experience rapid bone loss over a five-to-six-year period. Ideally, every woman should have a bone density screening at menopause, but health insurers won't often pay for the test at menopause unless a woman has symptoms of osteoporosis or is at significant risk for the condition. By knowing their bone health at the time of menopause, women could begin an appropriate treatment regimen before they start breaking bones. Postmenopausal women and men over age 65 should increase their daily intake of calcium.
  • At the time of the first fracture, which may be an early sign of osteoporosis. People who have a fracture should have an evaluation that includes a bone density test.
  • This section on preventing osteoporosis has information on:

    • Lifestyle choices
    • Diet
    • Medications, including hormone therapy or HT
    • Lifestyle choices

      Several lifestyle choices can influence the development of osteoporosis:

      Exercise: Exercise that forces you to work against gravity (weight-bearing exercises such as walking or jogging) is beneficial. Other weight-bearing exercises include racquet sports, hiking, aerobic dance, and stair climbing. The benefits of exercise last only as long as you maintain the program. If you are at risk for osteoporosis, your doctor will most likely include exercise as part of your overall treatment program.

      Body weight: Body weight is an important determinant of bone density. Studies have demonstrated that body weight is positively correlated with bone mineral density and that weight loss is associated with bone loss. (Increasing calcium intake appears to reduce the bone loss that accompanies weight loss.) Weight loss in older individuals has been linked to an increase in fracture risk. Researchers found that "extreme" weight loss (10 percent or more) beginning at age 50, increased the risk of hip fractures in older women and men. Conversely, a weight gain of 10 percent or more decreased hip fracture risk. Such studies suggest that maintaining weight in later life may have a protective effect on bone.

      Smoking: Cigarette smoking was first identified as a risk factor for osteoporosis more than 20 years ago. Subsequent studies have also demonstrated a direct relationship between tobacco use and decreased bone density. However, not all studies have supported this finding. While the association between tobacco use and decreased bone density is fairly strong, the results are less consistent when fractures are considered. Researchers have discovered that smoking cessation, even later in life, may help limit smoking-related bone loss.

      Diet

      You are more likely to develop osteoporosis if your body lacks sufficient amounts of calcium and vitamin D. To maintain strong, healthy bones, a diet rich in calcium is needed throughout your life. In both men and women, the need for calcium becomes even greater with age. Among post-menopausal women, studies have shown that supplemental calcium can decrease the rate of bone loss from the femoral neck, the spine, and the total body. Since calcium is a nutrient, not a drug, the positive effects of supplemental calcium are most pronounced among women with low to moderate calcium intake. Recent clinical trials have suggested that supplementation with calcium or calcium plus vitamin D can reduce fracture incidence by about 30 to 50 percent in subjects with low calcium intakes.

      This section on diet includes information on:

      • Calcium
      • Vitamin D
      • Soy
      • Other nutrients
      • Calcium

        The U.S. recommended daily allowance (RDA) for calcium is 1,000 milligrams per day. Post-menopausal women who are not taking estrogen should get 1,500 milligrams per day, as should men once they hit age 65. Recent studies indicate that many adults get only half or less of their daily calcium requirement. An 8-ounce glass of whole or skim milk, 1 ½ ounces of cheddar cheese, 2 cups of cottage cheese, and 1 cup of yogurt each contain an estimated 300 mg of calcium. Besides dairy products, other good sources of calcium are sardines, kale, broccoli, calcium-fortified juices and breads, dried figs, and calcium supplements.

        Keep track of your daily calcium intake for a week, and discuss this record with your doctor. You also may increase the calcium in foods by following these suggestions:

        • Add nonfat powdered milk to soups, casseroles, and drinks.
        • Replace sour cream with yogurt in recipes.
        • Some bottled waters contain calcium, so check the labels for more information.
        • If your diet doesn't contain enough of this vital nutrient, supplement your intake with calcium tablets. Ask your doctor or pharmacist to recommend a supplement that is well absorbed by your body.
        • Vitamin D

          This vitamin is also important because it enables the body to absorb calcium. The recommended daily allowance of vitamin D is 200 IU (international units). Vitamin D can easily be obtained by getting five to 15 minutes of sunlight a few times a week or by consuming fortified milk. Vitamin D is also found in fatty fish, eggs, liver, butter, fortified foods such as milk, and multivitamins. Vitamin D deficiency may be a problem among some elderly, those in institutional settings, and some people with chronic neurological or gastrointestinal diseases. Too much vitamin D is harmful, so don't decide to take supplements without first consulting your doctor. However, you probably can safely take 400 units a day.

          Soy

          The soybean plant, a legume, contains specific phytochemicals known as isoflavones. Phytochemicals are nonnutritive substances, in that they contain no vitamins or minerals. Isoflavones are also phytoestrogens. Phytoestrogens are compounds that have mild estrogenic effects.

          Chick peas and legumes are good sources of isoflavones. Soy has the greatest concentration of these chemicals. Isoflavones have received a good deal of attention for their possible cancer and heart disease-preventive traits. Because of their estrogenlike properties, many believe that isoflavones and other phytoestrogens may one day play a role in post-menopausal health.

          One isoflavone derivative, ipriflavone, is currently used outside the United States as an osteoporosis therapy. Ipriflavone has had a bone-protective effect in several studies. Further research is needed to understand the systemic effects of this compound before it can be considered a therapeutic approach for osteoporosis prevention and treatment.

          Other nutrients that influence osteoporosis

          Protein is essential in our diets to build tissue during growth and to repair and replace tissue throughout the life cycle. However, protein also increases the body's need for calcium by increasing calcium excretion. It is generally believed that most Americans exceed the recommended daily intake for protein—44 grams for women and 56 grams for men.

          Sodium (and chloride), the components of table salt, increase the calcium requirement by increasing urinary calcium excretion. Individuals with low salt intake may be able to maintain calcium balance at low calcium intake, while those with more typical U.S. salt intake will have higher calcium requirements.

          Oxalate is a nutrient that increases the calcium requirement by interfering with calcium absorption in the same food (not in others). Spinach, for example, is an extremely nutritious food, but its calcium is not absorbed because it is chemically bound to the oxalates that are present. However, eating spinach with cheese would not affect the absorption of calcium from the cheese. Foods high in oxalates include spinach, rhubarb, and sweet potatoes.

          Caffeine in a cup of coffee can reduce calcium absorption by a few milligrams. But that loss can be easily offset by adding a tablespoon or two of milk. Much of the apparently harmful effect of caffeine appears to be due not to the caffeine itself but to the fact that caffeine-containing beverages are often substituted for milk in the diet.

          Vitamin A is important for healthy bones. However, too much vitamin A has been linked to bone loss and an increase in the risk of hip fracture. Scientists believe that excessive amounts of vitamin A trigger an increase in osteoclasts, the cells that break down bone. They also believe that too much vitamin A may interfere with vitamin D. Healthy individuals who eat a balanced diet generally do not need a vitamin A supplement.

          Medications

          Several therapies currently are approved for the prevention of osteoporosis, many of which also are approved for treatment:

          Alendronate, raloxifene, and risedronate are approved by the U.S. Food and Drug Administration for the prevention and treatment of post-menopausal osteoporosis.

          Hormone therapy (HT) is approved for the prevention of post-menopausal osteoporosis. Because of recent study results showing the risks of estrogen, it is used more selectively than before.

          Alendronate

          Alendronate (brand name Fosamax) is a medication from the class of drugs called bisphosphonates. Like estrogen and raloxifene, alendronate is approved for both the prevention and treatment of osteoporosis. Alendronate is also used to treat the bone loss from glucocorticoid medications like prednisone or cortisone and is approved for the treatment of osteoporosis in men. In post-menopausal women with osteoporosis, the bisphosphonate alendronate reduces bone loss, increases bone density in both the spine and hip, and reduces the risk of both spine fractures and hip fractures.

          Side effects from alendronate are uncommon but may include abdominal or musculoskeletal pain, nausea, heartburn, or irritation of the esophagus. The medication should be taken on an empty stomach and with a full glass of water first thing in the morning. After taking alendronate, it is important to wait in an upright position for at least one half-hour, or preferably one hour, before the first food, beverage, or medication of the day.

          Raloxifene

          Raloxifene (brand name Evista) is approved for the prevention and treatment of post-menopausal osteoporosis. It is from a new class of drugs called selective estrogen receptor modulators (SERMs), which have been shown to have beneficial effects on bone mass and bone turnover and can reduce the incidence of vertebral fractures.

          While side effects are not common with raloxifene, those reported include hot flashes and deep vein thrombosis, the latter of which is also associated with estrogen therapy. Additional research studies on raloxifene will be ongoing for several more years.

          Risedronate sodium

          Risedronate sodium (brand name Actonel) is approved for the prevention and treatment of osteoporosis in post-menopausal women and for the prevention and treatment of glucocorticoid-induced osteoporosis in both men and women. Risedronate, a bisphosphonate, has been shown to slow or stop bone loss, increase bone mineral density, and reduce the risk of spine and nonspine fractures.

          In clinical trials, side effects of risedronate were minimal to moderate and those that were reported occurred equally among people taking the medication and those taking a placebo. Risedronate should be taken with a glass of water at least 30 minutes before the first food or beverage of the day other than water. After taking risedronate, it is important to remain in an upright position and refrain from eating for at least 30 minutes.

          Hormone therapy (HT)

          Hormone therapy has been shown to reduce bone loss, increase bone density in both the spine and hip, and reduce the risk of hip and spine fractures in post-menopausal women. HT is approved for the prevention of post-menopausal osteoporosis and is most commonly administered in the form of a pill or skin patch. When estrogen is taken alone, it can increase a woman's risk of developing cancer of the uterine lining (endometrial cancer). To eliminate this risk, physicians prescribe the hormone progestin in combination with estrogen (both estrogen alone and the combination fall under the umbrella of hormone therapy, or HT) for those women who have not had a hysterectomy. Side effects of HT include vaginal bleeding, breast tenderness, mood disturbances, venous blood clots, and gallbladder disease.

          The Women's Health Initiative (WHI), a large government-funded research study, recently demonstrated that HT with Prempro, a combination of supplemental estrogen and progesterone, is associated with a modest increase in the risk of stroke and heart attack. After five years, it is also associated with a small increased risk of breast cancer. The WHI also demonstrated that estrogen alone is associated with an increase in the risk of stroke. Another large study from the National Cancer Institute (NCI) indicated that long-term use of estrogen therapy may be associated with an increase in the risk of ovarian cancer. It is not yet clear whether HT carries a similar risk. Any estrogen therapy should be prescribed for the shortest period of time possible. When used solely for the prevention of post-menopausal osteoporosis, any hormone regimen should only be considered for women at significant risk of osteoporosis, and nonestrogen medications should be carefully considered.

          Last reviewed on 12/12/2006

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