Figure 1 - Osteoporosis makes bones less dense

About

Basics of osteoporosis

Incidence

Both the amount of bone mass you have as a young adult and how fast you lose it as you age determine your risk for osteoporosis. Throughout life, your body removes and replaces small amounts of old bone. The amount of bone you have is called bone mass. As you age, your bones lose mass and may become porous, or less dense. This happens because you lose more old bone than your body can replace.

Bones that have less mass are more likely to break or fracture, even in a minor fall. The first warning that you have osteoporosis may be a broken bone. Broken bones limit activities for many older adults.

Women

Women are at greater risk of losing bone mass than men because they start with 30 percent less than men and lose it faster after menopause. Caucasian and Asian women have less bone mass than African American women, which puts them at greater risk.

A third or more of the women in the United States over age 45 may be affected at any point in time. Half may experience a broken bone from osteoporosis during their lifetime.

Bone mass in women is affected by levels of the hormone estrogen. Bone mass builds in younger years, levels off at ages 30 to 35, and remains stable until menopause. After menopause, women lose bone mass rapidly, about two to three percent each year. This loss continues for five to ten years. Women are more likely to break bones in the wrist or spine in the years after menopause, usually from ages 45 to 60, because of the drop in estrogen levels. Fractures of the spine, can cause loss of height and rounded shoulders, sometimes called dowager's hump.

Hip fractures

Both men and women tend to break hips in their 70s and 80s. Since men are affected, factors other than lack of estrogen must be important in causing hip fractures.

Reducing your risk

You can take steps now to reduce your risk of developing osteoporosis. If you already have osteoporosis, many of the same steps for reducing your risk can be used as treatment.

Before age 35, your body is building bone mass. During these years, you can take steps to build as much bone mass as possible. These same steps may help slow the rate of bone loss later. The steps include: increasing calcium in your diet, avoiding smoking, avoiding heavy alcohol use, and doing weightbearing exercise regularly.

If you are a woman, your doctor may recommend taking estrogen after menopause to slow bone loss. For women, taking estrogen is one of the most effective ways to prevent fractures from osteoporosis.

As you get older, you are more likely to fall and break a bone. You can reduce your risk of falling with exercise, regular eye exams, good lighting, and home safety.

Checking your risk

Researchers cannot yet predict exactly who will develop osteoporosis. The check list below shows risk factors that are common in people with osteoporosis. If you have one or more of these risk factors, you are at greater risk of breaking a bone.

Risk factors you can change:

• Eating a low-calcium diet
• Smoking cigarettes
• Drinking more than two alcoholic drinks a day
• Not exercising regularly

Risk factors your doctor can help you change:

• Having low bone mass
• Going through menopause before age 45 (especially after surgery to remove the ovaries)
• Taking drugs that reduce bone strength (cortisone, anticonvulsants, or heparin)
• Having diseases that affect calcium levels (disorders of intestines, liver, kidneys, or glands that produce hormones)
• Having poor eyesight or balance

Risk factors you cannot change:

• Being female
• Being Caucasian or Asian
• Being thin and small-boned
• Having a history or wrist, spine, pelvic, or hip fractures

Prevention

Avoiding falls and injuries

Preventing falls, especially in the home, reduces your risk of fractures from osteoporosis. You may reduce your chances of falling with exercise, regular eye exams, and home safety.

As you get older, you may experience certain changes that increase your chances for falling and breaking a bone. These changes include loss of the ability to move easily, poor eyesight, and dizziness caused by illness or medications. Even a minor fall can break a bone already weakened by osteoporosis.

There are things you can do to reduce your risk of falling. Exercising regularly and wearing low-heeled shoes with firm, non-slip soles may help improve your balance. Having regular vision checks and wearing glasses, if you need them, can improve eyesight. Ask your doctor if you are taking any medications which might cause dizziness.

Many older people break a wrist or hip by falling at home. You can avoid falls by making your home a safer place. You can make your home safer in several simple ways:

Lights:

• Night lights in hallways, bathrooms, and bedrooms
• Flashlight beside the bed
• Hallways, stairs, and rooms well lit

Floors:

• No throw rugs, or use rugs with non-slip backing
• Carpet edges tacked down
• Non-skid wax on floors
• No electrical cords in walkways

Stairs:

• Light switches at top and bottom of stairs
• Stairs covered with non-slip surface
• Sturdy handrails

Bathroom:

• Handrails beside bathtub, toilet, and in shower
• Bathtub with rubber mats for traction

Kitchen:

• Items within easy reach
• Stable step stool for reaching items on top shelves

Diagnosis

You may not have symptoms of osteoporosis until you break a bone.

However, your doctor has ways to find out if you have it. The doctor may recommend measurements to determine your current bone mass. Your doctor may ask you questions about symptoms, especially when and where you feel pain. He or she may ask questions about your medical history, including your overall health, previous illnesses, past fractures, diet, and medications. A physical examination and blood and urine tests may be done to rule out other diseases that weaken bone. All this information helps your doctor find out if you have osteoporosis.

Treatment

Many of the steps you can take to prevent osteoporosis--such as increasing calcium, exercising regularly, and taking estrogen--may also be used to treat it.

Some treatments for osteoporosis may either increase bone formation or decrease bone loss. The doctor will treat fractures in other ways. The treatment may include casts, braces, or surgery. Other treatment may include physical therapy, muscle relaxants, pain relievers, and rest.

Hormones

Calcitonin is a hormone which occurs naturally in the body. It reduces the loss of bone mass and also helps relieve pain. This hormone is used to treat osteoporosis in women after menopause. Calcitonin may help reverse the loss of bone mass occurring in someone who has taken cortisone drugs for a long time. It is currently available by injection.

Estrogen is effective for women who have osteoporosis. Estrogen can increase bone mass by more than five percent and reduce fractures by half.

Diet

Increasing calcium

As a child, you were probably told to drink milk in order to build strong bones. Milk, other dairy foods, fruits, vegetables, and legumes (beans) contain a mineral called calcium. Calcium is one of the main building blocks of bone. You still need calcium as an adult. If the calcium level in your blood drops too low, your body takes calcium from the bones.

You may need to increase the amount of calcium in your diet. How much calcium you need depends on your sex, age, and risk for osteoporosis. Most adults need 1,000 to 1,500 milligrams of calcium a day from food and/or calcium supplements, but get only about half or 500 milligrams in their diets. Getting enough calcium is especially important if you're a woman under age 35, because your body is still able to absorb and store calcium in your bones easily. Experts recommend 1,500 milligrams per day for teens, pregnant or breast feeding women, and older adults. As you age, you need to take in more calcium, since your intestines don't absorb calcium as well. One study of elderly people showed that their risk of hip fracture was reduced when they took extra calcium.

Foods are the best natural source for calcium. You can increase the amount of calcium in your diet by eating more dairy foods. Dairy products--such as milk, cheese, and yogurt--have the highest amounts of calcium. An eight ounce glass of milk has about 300 milligrams, or one-fourth of your daily need for calcium. To avoid adding fat and calories to your diet, buy skim or low-fat dairy products. Other foods high in calcium include green leafy vegetables, shellfish, sardines, oysters, brazil nuts, tofu, and almonds. Some foods--such as orange juice, breads, and breakfast cereal--may be fortified with calcium.

If you do not like or cannot eat dairy foods, calcium supplements may make up for the calcium you don't get from food. Calcium supplements come in tablet or liquid form.

Supplements vary widely in the amount of calcium they contain for the price. Supplements of calcium carbonate contain the highest amount of useful or elemental calcium. If you take a calcium supplement, be sure to take it with meals and drink six to eight glasses of water each day.

Avoiding (or quitting) smoking

People who smoke cigarettes have a greater risk of fracture than nonsmokers. Smoking reduces bone mass. Smokers may have an increased risk because they often weigh five to ten pounds less than nonsmokers. Smoking lowers women's estrogen levels. Menopause begins at an earlier age for women smokers. Smoking is already linked to a number of other serious diseases, including cancer and heart disease. The link to osteoporosis adds one more reason to stop smoking or never start. People who smoke cigarettes have a greater risk of fracture than nonsmokers.

Avoiding heavy alcohol use

Men and women who drink a lot of alcohol have a higher risk for developing osteoporosis. People who drink heavily have less bone mass and lose bone more rapidly. This loss of bone mass may be the direct result of alcohol's effect on bone. Heavy drinking also increases your chances of falling and breaking a bone.

If you drink alcohol, experts recommend drinking no more than two drinks per day to keep bones healthy. One alcoholic drink is equal to 12 ounces of beer, five ounces of wine, or one and one half ounces of liquor.

Exercise and therapy

Exercises that place weight on, or increase the force of gravity against your bones, may help you keep bone mass. Changes in pressure and force that occur during daily activities and exercise cause bones to develop mass and strength. When you move your body against the force of gravity and do exercises that strengthen muscles, you are producing forces that push and pull on your bones. Bones respond to this kind of movement and become stronger.

You lose bone mass when you do not put weight on your bones. For instance, anyone who cannot get out of bed or does not walk loses bone mass and has an increased risk of fracture. Astronauts do special exercises while they are in space to keep from losing bone mass. This is important because they are weightless in space and cannot exercise against gravity.

Some exercises or activities that use gravity and your muscles to strengthen your bones are listed below. If you do them regularly and quickly, some are also good for your heart. Exercise helps you move more easily and keep your balance, which helps you avoid falls.

Helpful exercises and activities:

• Aerobics
• Ballroom/square dancing
• Cross-country skiing
• Household chores-standing (sweeping, vacuuming, etc.)
• Mowing the lawn
• Racquetball
• Rowing
• Running/jogging
• Stair climbing
• Tennis
• Walking/hiking

Doing regular exercise that puts weight on your bones helps keep them strong. Experts do not know exactly how long you must exercise to prevent loss of bone mass. Most guidelines for exercise apply to heart health, not bone health. A good guideline is to do some type of weightbearing exercise three to four times a week for a total of 20 to 30 minutes. You can exercise 10 or 15 minutes at a time, if you do not want to do it all at one time.

Many people are able to start exercising without talking to their doctors, if they start slowly and gradually. However, check with your doctor before starting an exercise program if you have not been physically active or you have any of the following:

• Osteoporosis or previous fractures after age 40
• Heart disease, high blood pressure, stroke, high cholesterol, or a family history of heart disease
• Pain or pressure in the chest, neck, shoulder, or arm during or after exercise
• Dizziness or extreme shortness of breath after mild exertion
• Any condition that might need medical attention before an exercise program begins, such as diabetes

Condition research

Researchers are studying other treatments for osteoporosis. Some treatments are already being used in other countries. However, they have not been approved by the United States Food and Drug Administration as treatments for osteoporosis.

Vitamin D is produced by the body in response to exposure to sunlight. It increases the amount of calcium that your body absorbs from the intestines, which is especially important in older people. One study showed that calcitriol, a powerful, hormonal form of Vitamin D prescribed by doctors, decreased fracture rates in women. Vitamin D can be toxic if taken in too large an amount--100 to 1000 times the recommended dose--and may lead to serious side effects, including kidney damage and high blood pressure.

Bisphosphorlates are compounds which have been found to decrease bone loss. Examples of bisphosphonates are alendronate, etidronate, clodronate, pamidronate, and tiludronate. They are being tested in the treatment of osteoporosis.

Calcitonin, in a nose spray form, is being studied as a treatment.

Sodium fluoride promotes new bone growth, but may not reduce the risk of fracture. The new bone which is formed may be weaker. However, new forms of this drug are being tested.

New methods are being developed to detect and treat osteoporosis. Your doctor is the best guide to finding the right treatment for you.

Credits

Some of this material may also be available in an Arthritis Foundation brochure. Contact the Washington/Alaska Chapter Helpline: (800) 542-0295. If dialing from outside of WA and AK, contact the National Helpline: (800) 283-7800.

Adapted from a pamphlet originally prepared for the Arthritis Foundation. This material is protected by copyright.

Surgery for Osteoporosis at the University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, Washington