Primary Prevention Primary Prevention of Osteoporosis and of Osteoporosis and

Bone HealthBone Health

Michael Zanovec, CDT

Research Associate

LSU School of Human Ecology

OverviewOverview

Osteoporosis is a skeletal disorder Osteoporosis is a skeletal disorder characterized by:characterized by:

Compromised bone strengthCompromised bone strength

Reflects bone density and bone qualityReflects bone density and bone quality

Increased susceptibility to fracturesIncreased susceptibility to fractures

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OverviewOverview

Osteoporosis causes weak bones.

In this common disease, bones lose minerals like calcium.

They become fragile and break easily.

Source: The 2004 Surgeon General’s Report on Bone Health and Osteoporosis:What It Means to You at http://www.surgeongeneral.gov/library/bonehealth

Normal bone

Osteoporotic bone

Risk Factors

FemaleFemale

White/CaucasianWhite/Caucasian

Post menopausal womanPost menopausal woman

Older adultOlder adult

Small body sizeSmall body size

Eating a diet low in calcium/vitamin DEating a diet low in calcium/vitamin D

Physically inactivePhysically inactive

Female athlete triadFemale athlete triad

Osteoporosis Prevalence

44 million Americans are at risk 44 million Americans are at risk

10 million Americans have the disease10 million Americans have the disease

~ 80% are women~ 80% are women

~ 20% of Caucasians~ 20% of Caucasians

~ 5% of African Americans~ 5% of African Americans

Bone Health and Osteoporosis: A Report of the SurgeonBone Health and Osteoporosis: A Report of the Surgeon

General, 2004General, 2004

Osteoporosis can strike at any age!Osteoporosis can strike at any age!

It is a myth that osteoporosis is only a problem for older women.

The “Silent Disease”

Bone loss occurs Bone loss occurs without symptoms.without symptoms.

A fracture may be A fracture may be the first sign. the first sign.

Collapsed vertebrae Collapsed vertebrae may cause pain, may cause pain, loss of height, or loss of height, or spinal deformities.spinal deformities.

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The 3 most The 3 most common breaks in common breaks in weak bones are in weak bones are in the:the:

1.1. hip hip

2.2. spinespine

3.3. wristwrist

Source: The 2004 Surgeon General’s Report on Bone Health and Osteoporosis:What It Means to You at http://www.surgeongeneral.gov/library/bonehealth

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Hip fractures Hip fractures account for account for 300,000 300,000 hospitalizations hospitalizations annually. annually.

People who break a hipmight not recover formonths or even years.

Source: The 2004 Surgeon General’s Report on Bone Health and Osteoporosis:What It Means to You at http://www.surgeongeneral.gov/library/bonehealth

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1 in 5 people with 1 in 5 people with a hip fracture end a hip fracture end up in a nursing up in a nursing home within a home within a year.year.

Some people never walk again.

Source: The 2004 Surgeon General’s Report on Bone Health and Osteoporosis:What It Means to You at http://www.surgeongeneral.gov/library/bonehealth

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A woman’s hip A woman’s hip fracture risk fracture risk equals her equals her combined risk of combined risk of breast, uterine breast, uterine and ovarian and ovarian cancer.cancer.

Source: National Osteoporosis Foundation Web site; retrieved July 2005 at http://www.nof.org

Burden of Bone Disease

Economic cost Economic cost -- Estimated direct expenditures Estimated direct expenditures (hospitals and nursing homes) for osteoporotic (hospitals and nursing homes) for osteoporotic

and associated fracturesand associated fractures:: $17 billion in 2001$17 billion in 2001

$47 million each day$47 million each day

Cost to the individual Cost to the individual –– osteoporosis causes osteoporosis causes frailty and reduced functional capacityfrailty and reduced functional capacity

Bones are living organs

Calcium is deposited and Calcium is deposited and withdrawn from bones daily.withdrawn from bones daily.

Bones build to about age 30.Bones build to about age 30.

We need to build up a We need to build up a healthy bone account while healthy bone account while young and continue to young and continue to make deposits with age.make deposits with age.

Types of Bone

Cortical boneCortical bone

Lining or “bark”Lining or “bark”

Trabecular boneTrabecular bone

StructureStructure

““trabtrab” meaning beams ” meaning beams or timberor timber

SpongySpongy

Bone composition

Cortical bone accounts for 80% of Cortical bone accounts for 80% of skeletal body massskeletal body mass

1/3 radius region of forearm: 100%1/3 radius region of forearm: 100%

Femoral neck: 75%Femoral neck: 75%

CancellousCancellous bone accounts for 20% of bone accounts for 20% of skeletal body massskeletal body mass

Spine: 66%Spine: 66%

Os calcis (heel): 95%Os calcis (heel): 95%

Healthy Bones

“Bone strength reflects the “Bone strength reflects the integration of two main features: integration of two main features: bone density bone density and and bone qualitybone quality.”.”

NIH Consensus Development Panel. NIH Consensus Development Panel. JAMAJAMA 2001:285:7852001:285:785--795.795.

Evaluation of Bone Health

Bone DensityBone Density

DualDual--Energy XEnergy X--ray Absorptiometry (DXA) ray Absorptiometry (DXA) ––

“gold standard” for detecting osteoporosis“gold standard” for detecting osteoporosis

Bone QualityBone Quality

Quantitative Ultrasound (QUS) Quantitative Ultrasound (QUS) –– measures measures

physical properties of bonephysical properties of bone

Bone Density

DXA ApparatusDXA Apparatus

FullFull--Size Table ModelsSize Table Models

Peripheral DXA DevicesPeripheral DXA Devices

DXA BMD Reports

BMD T-score Risk Assessment

The World Health OrganizationThe World Health Organization

classifications for white womenclassifications for white women

NormalNormal

TT--score greater than score greater than ––1.01.0

OsteopeniaOsteopenia

TT--score between score between ––1 and 1 and ––2.52.5

OsteoporosisOsteoporosis

TT--score below score below ––2.5 2.5

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Fracture Risk Doubles With Every SD Decrease in BMD

0

5

10

15

20

25

30

35

-5.0 -4.0 -3.0 -2.0 -1.0 0.0 1.0

Bone Density (T-score)

Relative Risk

for Fracture

Quantitative Ultrasound

Peripheral site (usually the Peripheral site (usually the calcaneus; ~95% trabecular bone)calcaneus; ~95% trabecular bone)

Assesses without ionizing radiationAssesses without ionizing radiation

PortablePortable

Less expensiveLess expensive

Relatively new technology in the Relatively new technology in the

USUS Approved by the FDA Center for Devices Approved by the FDA Center for Devices

and Radiological Health (Achilles Express) and Radiological Health (Achilles Express) in 1999. in 1999.

DOES NOT MEASURE BONE DENSITY!DOES NOT MEASURE BONE DENSITY!

Why the heel?

Considered the best peripheral Considered the best peripheral site for fracture risk site for fracture risk assessmentassessment

Easily accessibleEasily accessible

Metabolically active boneMetabolically active bone

High trabecular content (~90%)High trabecular content (~90%)

WeightWeight--bearing like the spine & bearing like the spine & femurfemur

Allows early detection and Allows early detection and interventionintervention

Bone Characteristics in Terms of Ultrasound Velocity and Attenuation

Measurements of Bone Measurements of Bone Quality:Quality:

1.1. Speed of Sound (SOS)Speed of Sound (SOS)

Bone elasticity and densityBone elasticity and density

2.2. Broadband Ultrasound Broadband Ultrasound Attenuation (BUA)Attenuation (BUA)

Trabecular density, spacing, Trabecular density, spacing, and orientationand orientation

Stiffness Index

Stiffness Index = BUA + SOSStiffness Index = BUA + SOS

SI = (0.67*BUA + 0.28*SOS)SI = (0.67*BUA + 0.28*SOS)-- 420)420)

Clinical measure with a lower precision Clinical measure with a lower precision error than either variable aloneerror than either variable alone

Stiffness Index T-score

DXA printoutQUS printout

What’s this person’s T-score?

Comparison of DXA and QUS

BUA and DXA measurementsare significant and independent predictors of hip fracture

Fracture Risk/1000 women

+ DXA & + BUA = 2.7+ DXA & - BUA = 6.2- DXA & + BUA = 11.8- DXA & - BUA = 19.6

+ = score above the mean- = score below the mean

Hans et al, Lancet, 1996

Conclusions

Bone health is a product of both bone Bone health is a product of both bone density and bone quality.density and bone quality.

Quantitative ultrasound appears to be a Quantitative ultrasound appears to be a effective bone quality screening tool.effective bone quality screening tool.

Quantitative ultrasound appears to be a Quantitative ultrasound appears to be a better screening tool for African better screening tool for African American women than for Caucasian American women than for Caucasian females. females.

Nutrition and Osteoporosis

Build Your Bones!

The amount of bone tissue The amount of bone tissue can continue to grow until can continue to grow until approximately 30 years of approximately 30 years of age.age.

At that point, bones reach At that point, bones reach their maximum strength and their maximum strength and density, known as peak bone density, known as peak bone mass.mass.

Attainment of peak bone mass Attainment of peak bone mass is one of the most important is one of the most important strategies for preventing strategies for preventing osteoporosis.osteoporosis.

3 Keys to Bone Health

1.1. Weight bearing physical Weight bearing physical activityactivity

2.2. Calcium Calcium

3.3. Vitamin DVitamin D

Exercise for Bone Health

Weight bearing physical activityWeight bearing physical activity

Make your bones and muscles work Make your bones and muscles work against gravity with jogging, walking, stair against gravity with jogging, walking, stair climbing, dancing, and soccer.climbing, dancing, and soccer.

ResistanceResistance

Build your muscular strength with weight Build your muscular strength with weight liftinglifting

Exercise for Bone Health

Moderate intensity exerciseModerate intensity exercise at least 30 at least 30 minutesminutes most days of the weekmost days of the week to maintain health.

Moderate intensity activity Moderate intensity activity 60 minutes 60 minutes most most days of the weekdays of the week to maintain weight and to maintain weight and prevent future weight gain.prevent future weight gain.

U. S. Dietary Guidelines 2005

Eat Right for Bone Health

Calcium Calcium –– DRI Adequate Intake (AI)DRI Adequate Intake (AI)

1,000 mg/day 1,000 mg/day for men and women 19for men and women 19--50 yrs of age50 yrs of age

1,200 mg/day for men and women 51 and older1,200 mg/day for men and women 51 and older

Vitamin DVitamin D

200 IU/day 200 IU/day for men and women 19for men and women 19--50 yrs of age50 yrs of age (Sunshine 10(Sunshine 10--15 min/day during the summer months)15 min/day during the summer months)

400 IU/day for men and women 51400 IU/day for men and women 51--70 yrs of age70 yrs of age

600 IU/day for men and women > 70 years of age600 IU/day for men and women > 70 years of age

Fruits and vegetables (U. S. Dietary Guidelines, 2005)Fruits and vegetables (U. S. Dietary Guidelines, 2005)

2 cups/day (4 servings) of fruits 2 cups/day (4 servings) of fruits

2.5 cups/day (5 servings) of vegetables2.5 cups/day (5 servings) of vegetables

Keys to Bone Health

Be physically activeBe physically active

Eat a wellEat a well--balanced diet rich in calcium balanced diet rich in calcium and vitamin Dand vitamin D

Get plenty of sunshineGet plenty of sunshine

Don’t smokeDon’t smoke

If you drink alcohol do so in If you drink alcohol do so in moderationmoderation