Heather EatsonPeterborough & Area

ManagerOntario Osteoporosis

Strategy

Osteoporosis Canada

Ontario Osteoporosis Strategy

GOAL:

To reduce fractures, morbidity, mortality and costs from osteoporosis…

through an integrated and comprehensive approach aimed at health promotion and disease management.

Background

October 2000: “A Framework and Strategy for the Prevention and Management of Osteoporosis”

May 2002:“Osteoporosis Action Plan: An Osteoporosis Strategy for Ontario”

February 22nd, 2005: MOHLTC announced the launch of Ontario’s first Osteoporosis Strategy

Identification of service gaps

Low public awareness

Inappropriate diagnostic testing

Lack of adequate management

Lack of clinically useful information

Lack of integrated post-fracture care protocols

Osteoporosis Strategy: 5 Components

Health Promotion

1. Education programs for seniors and children:

– Increase seniors knowledge of osteoporosis and improving bone health

– Increase bone health education in schools

Disease Management

2. Improve the use, and accuracy of bone mineral diagnostic testing (BMD) to increase early diagnosis of osteoporosis

3. Integration of fracture care, rehabilitation and osteoporosis management

4. Improve evidence based practice by Health Professionals

5. Research and evaluation

What Is Osteoporosis?

Normal Bone Osteoporosis- (Porous Bone)

“Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture.”1

1. Consensus Development Conference, JAMA 2001; 285: 785-95.

Osteoporosis is a…

potentially crippling disease characterized by low bone

mass (density) and deterioration of bone tissue, a

condition that can lead to increased bone fragility and

risk of fracture- most often at the spine, wrist or hip.

Common Fracture Sites

Overview on Osteoporosis

• Bone loss occurs without symptoms- The Silent Thief

• Osteoporosis can result in disfigurement, lowered self-esteem, reduction or loss of mobility, and decreased independence

• 1.4 million Canadians live with Osteoporosis• Healthcare costs are estimated to be $1.9 billion

each year in Canada

Hip fractures Hip fractures related to osteoporosis are a serious problem in older people

Approx. 25,000 hip fractures each

year in Canada (70% are osteoporosis related)

Hip fractures result in death in up to 20% and disability in up to 50% of those who survive

• Osteoporosis is a major public health issue in Canada

• Osteoporosis is diagnosed and treated by a variety of specialists and family physicians

• Osteoporotic fracture cases are treated almost exclusively by orthopaedic surgeons

The Evidence

• The majority of individuals who sustain fragility fractures are not receiving adequate osteoporosis management

– Less than 32% of fracture patients are investigated for osteoporosis.

Elliot-Gibson et al, 2004

Fragility Fractures…

“ a fracture caused by injury that would be insufficient to fracture normal bone: the result of reduced compressive and/ or torsional strength of bone ”

– Minimal trauma– From standing height, or less

WHO, 1998

Post- Fracture Care

Osteoporosis Screening Coordinators

• Increase the rate of referral of fragility fracture patients for assessment and treatment of OP, in order to reduce the risk of re-fracture

What does OP Screening Coordinator do?

• Identify all men and women 50+ who have suffered a fragility fracture

• Assess patient for OP risk factors

• Encourage patient to see family physician for further OP assessment

• Educate identified patient

• Follow up evaluation- 3/6 month

Long-Term Outcome Goals

• To increase preventive health behaviours in patients who have sustained a fragility fracture.

• Lower rates of subsequent fracture in this high-risk patient population, particularly hip fractures.

• Lower fragility fracture-related health care costs for the hospital and provincial government.

Other Initiatives

• Low Volume Fracture Screening

• Fracture Fighters – Rehab component

• Break Through – Adult Education

• Bone Fit – Osteoporosis Fitness Cert.

1 in 4 women 1 in 8 men

Osteoporosis: An Overview

Who Gets Osteoporosis?

How strong are your bones?

• Healthy strong bones are critical in preventing fractures.

• Bone is renewed through a process in which old bone is removed and replaced by new bone.

The Remodeling Process: How Bone Repairs Itself

Normal Growth and Development of Bone

• Genetics• Hormones• Nutrition• Physical activity

Four Major Factors that Contribute to Bone Health

Risk Factors

• Certain factors appear to play a role in the development of Osteoporosis

• These are called “risk factors”

• There are both minor and major risk factors

• Age 65• Vertebral compression

fracture• Fragility fracture after age 40• Family history of

osteoporotic fracture• Systemic glucocorticoid use

> 3 months

• Malabsorption syndrome• Primary

Hyperparathyroidism• Propensity to fall• Osteopenia apparent on x-

ray• Hypogonadism• Early menopause (before

age 45)

Diagnosis of Osteoporosis

Assessing Your Risk Factors: Major Risk Factors

Diagnosis of Osteoporosis

Assessing Your Risk Factors: Minor Risk Factors

• Rheumatoid Arthritis• History of clinical

hyperthyroidism• Chronic anticonvulsant

therapy• Low dietary calcium

intake• Smoker

• Excess alcohol• Excess caffeine • Low body weight (<57 kg

or 125 lbs)• Weight loss > 10% of

weight at age 25• Chronic heparin therapy

• Everyone over the age of 50 should assess their risk factors with their physician.

• Those individuals with at least one major or two minor risk factors should have a bone mineral density (BMD) test.

• Everyone age 65 and over should have a bone mineral density (BMD) test.

Review Your Risk Factors with Your Physician

Diagnosis of Osteoporosis

Bone Densitometry

Determining Your 10-year Absolute Fracture Risk

• Factors that influence this are:• BMD results• Age• Gender• Fracture history• Family history• Glucocorticoid (steroid) use

Goals of Osteoporosis Management

• bone loss

• Maintain and/or increase bone density

• Reduce the risk of fracture(s)

Slow bone erosion

Bisphosphonates include: Etidronate (Didrocal ) Alendronate (Fosamax,

Fosavance ) Risedronate(Actonel ) Zoledronic Acid (Aclasta)

SERMs-Raloxifene( Evista)Calcitonin (Miacalcin)

Speed up bone building

Parathyroid hormone (PTH ) Teriparatide (Forteo) a daily

subcutaneous injection for 18 months

Drug Therapies

Age Daily Intake

Children (4 – 8) 800 mg

Adolescents (9 – 18) 1300 mg

Men & women (19 – 49) 1000 mg

Men & women (50+) 1500 mg

Pregnant or lactating women (> 18 years) 1000 mg

Calcium: OC’s Daily Recommended Intake

Eat foods high in Calcium

• Dairy sources- whole and skim milk products, cheese, yogurt

• Fortified beverages• Fish bones-salmon,

sardines• Vegs- broccoli, bok

choy, kale

Calcium Content of Some Foods

Milk – all 1cup 300mg

Yogurt ¾ cup 295mg

Cheese-hard 245mg

Ice cream ½ cup 80mg

Salmon/bones ½ can 240mg

Beans,baked ½ cup 75mg

Broccoli,cooked ¾ cup 50mg

Orange 1 med 50mg

What are they made of?How do I choose one?What is the best way to take them?Which types are recommended?

Osteoporosis Prevention

Calcium Supplements: Questions & Answers

Age Daily Intake

Men & women (19 – 50) 400 IU

Men & women (50+) 800 IU

Pregnant or lactating women (> 18 years)

400 IU

Osteoporosis Prevention

Vitamin D: OSC’s Daily Recommended Intake

Where to find Vitamin D?

• Foods that are a natural source of Vit D – fish oils, eggs, chicken livers, salmon and sardines

• Foods fortified with Vit D - milk, margarine, some yogurts, some soy

beverages (check labels)• Vit D supplement, Multi vitamin, calcium

supplement with Vit D

Physical Activity

• Regular weight bearing activity

• Resistance exercise

Weight Bearing Exercise

Some examples of weight-bearing physical activities are…

• Walking, running, stair climbing, dancing

• Games and sports such as badminton, tennis, basketball, volleyball etc

Resistance Exercises

These involve moving objects or your own weight to create resistance

• Common forms of resistance exercise include:• Weight – training with barbells, dumbbells,

household objects or wrist weights• Strength training with equipment in a gym or

health club

Exercise with Caution

Check with a physician before starting any exercise program

• Don’t do exercise that causes pain• Warm up before exercise and stretch well after

exercising• Choose a facility, leader or trainer who knows the

exercise restrictions associated with osteoporosis• Choose an activity or program that is enjoyable

Living with Osteoporosis

Some

Movements

Should be

Avoided

Healthier bones - works with calcium & vitamin D to build strong bones

Better coordination and balanceImproved muscle strength and flexibilityIncreased endurance for daily activitiesImproved posture

Osteoporosis Prevention

The Benefits of Being Physically Active

Balance & Falls Prevention

• 1 in 3 seniors 65+ falls each year• 1 in 2 seniors 80+ falls each year• The fall-related injury is 9x greater in seniors than

among those under 65• Vitamin D has been shown to reduce falls• Exercise has been shown to decrease falls as well

as the risk of falls if exercise includes activities aimed at improving balance.

Personal costs after a Fall

• Pain and suffering

• Loss of independence

• Increased risk of falling- fall cycle

• Falls cause 90% of all hip fractures in seniors

• Almost half of all falls occur in/around home

• Knowing/Assessing your risks• Bone Mineral Density Testing• Medication• Diet – Calcium and Vitamin D• Exercise – Wt Bearing and Resistance Training• Falls and Safety Prevention

The Key Messages for Osteoporosis

Osteoporosis Canada

• 1-800-463-6842 (English)

• 1-800-977-1778 (French)

• www.osteoporosis.ca

• COPN (Canadian Osteoporosis Patient Network)