Osteoporosis

Prepared by

Angela Silipena

April 30, 2012

Prepared for

Dr. Elizabeth CalamidasAssociate Professor of Public Health

School of Health SciencesRichard Stockton College of New Jersey

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Introduction

The National Institute of Health describes osteoporosis (2001) as a “systematic skeletal

disease” (National Institutes of Health and Consensus Development Panel, Nazarko, 2011). The

United States Library of Medicine has declared it as “the most common type of bone disease”

that has become a silent epidemic (Nazarko, 2011, p 111) and recognized as a major health

problem throughout the world (Bindu et al, 2011). It is classified as a silent epidemic because it

can progress in an individual for decades without their knowledge (Ford, Bass, & Keathley,

2007; National Center for Biotechnology Information). In addition, the incidence rate is

anticipated to increase as the population ages (McBane, 2011). Osteoporosis is identified with

decreased bone mass that leads to the risk of bone fractures (Magdalena & Grazyna, 2008). An

individual usually doesn’t know they have the disease until a bone breaks (Nazarko, 2011).

There are two types of osteoporosis; type 1 is identified among postmenopausal women, while

type 2 is associated with eating disorders, coeliac disease, inflammatory bowel disease, kidney

disease, rheumatoid arthritis, hormone deficiency in men, and as a result of long term usage of

corticosteroids (Hannan et al, 2000).

The Surgeon General’s Perspectives (2010) states that osteoporosis can be seen in every

demographic group. A man or a woman can develop osteoporosis no matter what their ethnicity

or race, while women have a greater likelihood to develop osteoporosis than men (Bindu et al,

2011). The prevalence of the disease is ever increasing, and has been hypothesized by the

Surgeon General to be a result of “disconnect between patients and healthcare providers” (The

Surgeon General’s Perspectives, p369). In addition, The Surgeon General’s Perspectives

estimates that 40 million Americans have lower than normal bone mass, and in eight years 14

million men and women are anticipated to be affected with osteoporosis. Specifically, 50% of all

OSTEOPOROSIS 2

women and 20% of all men will develop the disease (Nazarko, 2011). Bones have a continuous

process of remodeling from osteoblasts and osteoclasts (Bindu et al, 2011). In osteoporosis,

osteoblasts underperform bone formation and osteoclasts perform bone resporption (Bindu et al,

2011), and as a result bone formation declines significantly (Ashuma et al, 2005). Therefore,

osteoporosis is a result of unequal activity between osteoblasts (National Center for Biomedical

Ontology). Diseases and drugs increase the likelihood of osteoporosis due to a higher than

normal bone degeneration (Nazarko, 2011).

Osteoporosis affects 10 million Americans (National Osteoporosis Foundation, 2011b;

The Surgeon General’s Perspectives, 2010). Out of the 10 million with osteoporosis, 80% are

women (Surgeon General’s Perspectives, 2010 NOF, 2011b).An estimated 34 million Americans

are at risk of getting osteoporosis (NOF, 2011b). Osteoporosis progresses without obvious

symptoms (Bindu et al, 2011). Meanwhile, individuals have a higher risk of acquiring

osteoporosis if their family has a history of the disease (NCBI, 2010). The populations at greatest

risk for having the disease are women over 50 and men over 70. Evidence has further allowed for

The Surgeon General’s Perspectives (2010), The National Institute of Arthritis and

Muskoskeletal and Skin Diseases (2011), and Joao Vianney et al (2002) to express that the

population at risk are older Asian and Caucasian women. In addition, Caucasian women living in

Northern Europe or North America are classified as the highest risk population (Wehren &

Magaziner, 2003). A Caucasian is 2.5 times more at risk for osteoporosis than a black woman

(Snelling et al, 2001). In addition, Caucasian men are at a greater risk for osteoporosis than

black men because of a greater bone density (Tracey et al, 2005). Another factor that influences

the onset of osteoporosis is an individual with low levels of appropriate testosterone or estrogen

levels (Joao Vianney et al, 2002). Menopause in women decreases estrogen levels in the body,

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and this is the main relationship in individuals with osteoporosis (NCBI, 2010). The World

Health Organization predicts that 30% of all postmenopausal women have osteoporosis.

Furthermore, it is “a more progressive disease in postmenopausal women” (Imai, 2010, p 34).

Obesity is related to a decline in estrogen levels in a woman (Freeman et al, 2010). Eating

disorders such as anorexia also reduces levels of estrogen in the body (Nazarko, 2011). On the

other hand, women that are underweight are twice more susceptible to osteoporosis than women

of healthy weight (Ravn et al, 1999).

Bone Health

The National Osteoporosis Foundation (2011c) has acknowledged that low calcium in an

individual’s diet is linked to poor bone density. Insufficient calcium intake makes an individual

more prone to osteoporosis (National Institute of Arthritis and Musculoskeletal and Skin

Diseases, 2010). Specifically, Type 2 Osteoporosis is identified with calcium deficiencies.

Despite the essential functions of calcium, such as contributing as a blood coagulant, nerve

signaling, and assisting in muscle contraction, the human body does not produce it (NOF,

2011c). When an individual does not intake enough calcium to sustain the body’s functions, it

gets excreted from the bones (NOF, 2011c). Calcium is further lost through excretion of bowels

and urine, hair, perspiration, and skin (NOF, 2011c).

The greatest defense for achieving bone health is by acquiring peak bone mineral density

(Ford, Bass, and Keathley, 2007). Eighty-five percent of bone mass develops by 18 year of age

in girls and by age 20 in boys (NOF, 2011b), while peak bone mass is achieved at age 30 for men

and women (NIAMS, 2010). Based upon studies, black women develop a greater bone density

and then lose it at a slower rate than white women (Aloia et al, 1996; Nelson et al, 2004). In

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addition, according to studies by Kaptoge et al (2003), men lose bone mass at a slower rate than

women and have stronger bones. Bone strength is determined according to its quality and density

(Bindu et al, 2011), while loss of bone mass is associated with increasing age (Rie & Masayoshi,

1999). Furthermore, the less dense a bone is, the more fragile it becomes (NOF, 2011b). There is

a direct correlation between lowered bone density and an increased risk of fractures (Nazarko,

2011). Bones are more at risk to break if proteins and minerals (calcium and phosphate) are

insufficient (Sutcliffe, 2005). Excess calcium and phosphate absorption also causes bone to lose

density as a person ages (NCBI, 2010).

According to the NOF (2011c), the best source of calcium is from foods such as non-fat

milk, yogurt, and cheese. One serving of 8oz milk and one serving of 6oz yogurt accounts for

300mg of calcium, while 1oz of cheese accounts for 200 mg (NOF, 2011c). Lactose intolerance

can be overcome in dairy foods like cheddar and swiss cheese and by having small portions of

dairy with a meal (NOF, 2011d). Adequate calcium intake can also be met in the form of

supplements (Nazarko, 2011). Based on a study by Ranganathan et al (2005), women who had

dairy products in their diet had a better intake of calcium than women who did not. Ford, Bass,

and Keathley (2007) identified in their findings that only 56% of women of survey acquired

adequate calcium daily. Additionally, findings from a study by Kasper et al (2001) indicated that

only 6.6% of their subjects met the recommended intake amounts for calcium in reference to the

standards set by the National Institute of Health. This small percentage has been hypothesized

by as a result of Ford, Bass, and Keathley’s findings (2007) that proper calcium intake could be

negatively impacted by food choices that are higher in calories than desired. This is concerning

according to NCBI’s reference that inadequate calcium intake in a person’s diet is an associated

risk factor for developing osteoporosis. The NOF (2011c) estimates that a typical diet only

OSTEOPOROSIS 5

equates to 250 milligrams of calcium per day. Postmenopausal women are recommended to

intake 700 milligrams daily, men under 50 and over 70 need 1,000 milligrams daily, and men

and women 71 and older need 1,200 milligrams daily (NOF, 2011c).

Vitamin D also plays a vital role in bone health because it is required for calcium to be

absorbed in the body (NOF, 2011d). Vitamin D can easily be obtained by sun exposure

(Nazarko, 2011). As little as thirty minutes, even in the winter satisfies the daily requirements

for an individual, while those with darker skin require more (Nazarko, 2011). Vitamin D can be

found in foods such as eggs, margarine, and oily fish (Nazarko, 2011). Pasteurized dairy milk

has vitamin D added by fortification (NOF, 2011d). Macdonald et al (2010) expressed deficiency

in Vitamin D as a concern. According to Nazarko (2011), younger individuals are less likely than

older aged individuals to be Vitamin D deficient, explained by their higher exposure to sunlight.

According to researchers in London, 12.5% of Caucasians, 25% of Afro-Caribbean’s, and 33%

of Asians are Vitamin D deficient (Ford et al, 2006). Clinicians have associated bone fractures

with Vitamin D deficiency (Bischoff-Ferrari, 2006). Deficient calcium and/or Vitamin D

absorption makes osteoporosis more likely (Joao Vinney et al 2002). Women tend to have less

sufficiency for Vitamin D than men (Nazarko, 2011). Men and women under age 50 need 400-

800 IU (international units) of vitamin D per day, and men and women 50 and older need 800-

1,000 IU per day (NOF, 2011c). On the other hand, excessive intake of vitamins and minerals

can decrease osteoclast activity (Joao Vianney et al, 2002).

Diet

The NCBI promotes bone health with recommendations for an individual’s diet to have

the right amounts of calcium, Vitamin D, and protein. The NOF( 2011d) also states that bone

OSTEOPOROSIS 6

health can also be achieved by getting adequate protein in the amounts of 5 ounces per day for a

woman and 5.5 ounces per day for men. Bone health can also be achieved with a balanced diet

with fruits and vegetables (NOF, 2011d). Studies indicate a correlation between healthy bones

and fruits and vegetables (NOF, 2011d). Wheat bran reduces the absorption of calcium when

consumed together, as well as drinking up to 3 cups of coffee per day (NOF, 2011d). According

to the NOF, the phosphoric acid and phosphate in cola beverages “may contribute to bone loss”

(2011d), and according to experts, Americans consume excess phosphorus. In addition, foods

high in sodium such as processed, canned, and high amounts of salt can be harmful to retaining

calcium (NOF, 2011d). Based on a study by Ford, Bass, & Keathley (2007), 84% of participants

in their survey were aware that their diet is an influence on developing osteoporosis, while 90%

knew that calcium in their diet reduced their risk for developing osteoporosis.

Impacts

Most people with osteoporosis don’t know they have the disease until a bone fracture

occurs (Bindu et al, 2010). Osteoporotic changes of the body increases an individual’s

inclination for falls and consequent injury (Nazarko, 2011). Daily activities may result in a

broken bone in an individual with osteoporosis (NOF). The greatest risks for fracture are the

spine, hip, and forearm (NOF; Imai, 2010). Approximately 230,000 bone fractures are caused by

bone fractures every year (Nazarko, 2011). Furthermore, 10% of osteoporosis fractures occur in

the hip (Imai, 2010). According to Bindu et al (2010), 76,000 people fracture their hips every

year. It has been anticipated that 50% of all women with osteoporosis over the age of 50 will

most likely fracture a bone in the hip, wrist, or vertebrae (NCBI, 2010).

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According to the NCBI (2010), weakened bones can cause debilitating effects. Fractures

cause chronic pain and deformity, affecting an individual’s posture and gait (Nazarko, 2011).

Having a bone fracture makes an individual more prone to osteoporosis (Joao Vianney et al,

2002). The World Health Organization predicts that half of all the women with osteoporosis have

suffered from a bone fracture. Spinal fractures are common in women with osteoporosis (Bindu

et al, 2011). More so, 25% of all women after menopause suffer from a spinal fracture (Nazarko,

2011; Imai, 2010).

The consequence of a fracture in the vertebral column is chronic pain and decreased

quality of life (Imai, 2010). In 2010, The Surgeon General’s Perspective (2010) has stated that

hip fractures are the largest cause for disability. Hip fractures can cause an individual to lose

their ability to walk (NCBI). After an unintentional injury due to a fall, most people require

assisted living such as a nursing home, especially after breaking a hip (NCBI, 2010; NOF,

2011b). The Department of Health and Human Services anticipates that 1 in 5 individuals with a

hip fracture will be in a nursing home within a year of the injury. The consequences of hip

fractures are decreased mobility, independence, and increased social isolation and physical

limitations (NOF, 2011b). These physical limitations of daily living include bending, twisting,

and lifting (NOF, 2011b). The Surgeon General’s Perspectives stated that recovery after breaking

a bone declines as age decreases. Meanwhile, hip fractures influence morbidity in the elderly.

Specifically, 20% of elderly people who break a hip die within 1 year of the sustained injury

(NOF, 2011b). Ford, Bass, and Keathley (2007) and Campion and Maricic (2003), men have a

greater risk for morbidity than women, especially after a hip fracture (31% vs. 17%). 15,802

people died in 2005 from injuries sustained after a fall (NOF, 2011b). In the later stage of the

disease, pain is common and sourced from bone fractures and bone tenderness (NCBI, 2010).

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Diagnosis

A person with osteoporosis is expected to have a normal life expectancy (NCBI, 2010).

Osteoporosis is diagnosed according to an assessment of fracture anticipation (Imai, 2010).

Furthermore, the diagnosis of osteoporosis is based on bone compositions that are significant

determinants of bone fracture risk (Bindu et al, 2011). According to Ford, Bass, & Keathley

(2007), early screening is critical for identifying osteoporosis. Early detection of the disease is

strived for by researcher and clinicians (Imai, 2010). The DHHS recognizes that the impact of

osteoporosis on an individual is dependent on proper diagnosis, usually with bone mineral

density testing. Imai (2010) specified that the “in the management and treatment of osteoporosis,

the target is to assess fracture risk and the endpoint is to prevent fractures” (p 41).

The WHO has established the diagnosis of osteoporosis within use of bone mineral

density (BMD) values. According to Bindu et al (2011), BMD is essential to diagnosing

successfully. In addition, there is no established method for assessing the quality of bone.

Although it is very beneficial to measure the mass of a bone in the spine, it has deemed a

problem thus far because of “the low ratio of bone to soft tissue…and the irregular configuration

of the vertebrae” (Bindu et al, 2011 p 6). All measurement techniques are inaccurate in

measuring an individual’s bone mass (Prentice, 2004). BMD tests are used to predict a person’s

risk for bone fractures (NCBI). BMD can be identified in multiple locations of the body such as

the forearm, heel, and spine (Bindu et al, 2011). It has been found that in postmenopausal

women, bone degeneration is more immediately identifiable in the trabecular bone of the spine

than in the peripheral bones (Bindu et al, 2011). The NOF (2011a) recommends that if an

individual breaks a bone after the age of 50 to have a bone density test (BMD). Unfortunately,

the detection of bone loss can only be noticed at a decline of 50% of bone mass (Nazarko, 2011).

OSTEOPOROSIS 9

BMD is not an entirely reliable measure because of low test sensitivity, it can only account for

50%-80% of bone strength (Imai, 2010). After diagnosis, a person undergoes monitoring of their

bone density every 1-2 years (NCBI, 2010). The costs of screening for osteoporosis make it more

difficult to anticipate a universal screening method anytime soon (Ingle et al, 2005).

Costs

Osteoporosis carries a significant negative social and financial impact (Bindu et al, 2011).

The disease diagnosis, treatment, and rehabilitation of bone fractures are expensive (Zethraeus et

al, 2002). According to the Surgeon General’s Perspectives, the financial impact of fractures

related to osteoporosis costs $19 billion every year in the United States. In 2005, this cost was a

result of 2 million bone fractures (NOF, 2011b). The fastest growth in osteoporosis in respects to

ethnicity has been identified in Hispanic women (NOF, 2011b). In 20 years from 2005 to 2025,

Hispanic fracture expenses will increase from $754 million to $2 billion per year (NOF, 2011b).

Treatment

Treatment for osteoporosis begins after proper diagnosis with the use of bone density

measurement (NCBI, 2010). Treating osteoporosis is intended to help reduce the rate at which

bone strength declines (NCBI, 2010). According to DHHS, medications can help reduce and

prevent bone health decline. Drug therapy can increase bone strength and decrease future bone

decline (Nazarko, 2011). It can further help with pain management (NCBI, 2010). According to

Boonen et al (2005), medications can reduce the risk for fracture, especially in the spine and hip.

Yood et al (2008) expressed that, “once treatment with osteoporosis medication is initiated, the

patient must then adhere to the medication regimen to achieve full therapeutic benefits” (p 1815).

Bisphosphonates are the most common method of treating and preventing osteoporosis in women

OSTEOPOROSIS 10

after menopause (NCBI, 2010), and are a reliable means of therapy (Imai, 2010).

Bisphosphonates manipulate bone remodeling in an individual by interfering with osteoclasts

and not with osteoblasts (Nazarko, 2011). This treatment method increases bone strength, and

also reduced the risk of bone fractures (Nazarko, 2011). Etidronate, alendronate, and Risedronate

are three types of prescribed Bisphosphonates for treating osteoporosis (Nazarko, 2011).

Raloxifen is a drug therapy used for prevention and treatment of osteoporosis (NCBI, 2010). It is

helpful towards reducing spinal fractures and has been shown to be effective by almost 50%

(NCBI, 2010). In a trial study indicated by Imai (2010) 7,700 women that were treated with

Raloxifene reduced their risk for fracture by 40%. Tetraparatide is a hormone therapy usually

prescribed to severe cases of osteoporosis in postmenopausal women (NCBI, 2010). Calcitonon

reduces the rate if bone health decline, while also beneficial for managing pain (NCBI, 2010). A

more current drug therapy is Strontium Ranelate, and according to Nazarko (2011), it reduces

bone resporption while it enhances bone formation. Nazarko (2011) further indicated that this

therapy is generally used for individuals who cannot take Bisphosphonates with ease. It is also

recommended by the NOF (2011c) that women with osteoporosis intake 1,000mg of calcium

daily. In addition, it is important that individuals are aware of potential for negative interactions

between medications and supplement. Therapy prior to a bone fracture can reduce the negative

consequences of an injury (Bindu et al, 2011). Findings of a study conducted by Yood et al

(2008) indicated that “the decision to initiate osteoporosis treatment is strongly dependent upon

the patients beliefs in the effectiveness of osteoporotic medications, and patient distrust of

medications” (p1820).

Falls

OSTEOPOROSIS 11

The American Association of Clinical Endocrinologists advises among treatment to take

precautionary measures to reduce the likelihood of falling. Mays (2000) suggests that our

environment, rather than our genetics is responsible for the breakage of bones due to harder

surfaces. Aspray et al (1996) indicated that decreased muscle control and coordination

negatively impacts the balance a person is capable of, and this increases the likelihood of falling

and subsequent injury. Nazarko (2006) encourages exercise to increase muscle coordination and

strength to further reduce the risk of a fall. Meanwhile, high impact exercises are discouraged, as

they increase the risk of an injury. Instead, walking, jogging, dancing, balance exercises,

stationary bikes, and ergometers are encouraged forms of exercise for individuals with

osteoporosis (NCBI, 2010). The NCBI further recommends that individuals use caution in their

home to prevent injury. Caution is especially important to Cummings, Nevitt & Kidd (1988)

because, “the cause of falls is often difficult to explain given one-third of the victims are unable

to recall the circumstances of the event” (p 614).

Falls can be prevented with the use of safety bars, especially in the shower (NCBI, 2010). Shoes

that fit properly can also help prevent falls (NCBI, 2010). In addition, an individual’s poor vision

can also put them at a greater risk of injury in the home (NCBI, 2010).

Education

Education for preventing osteoporosis is imperative to reduce its occurrence (Bindu et al,

2011). Osteoporosis can be prevented and reduced with awareness, education, and behavior

(Ford, Bass, & Keathley, 2007). The Surgeon General’s Perspective (2010) addressed urgency

for a National Action Plan and an increase of health literacy to help prevent and reduce

osteoporosis. It is intended to improve the overall health for Americans (DHHS, 2010). Kasper

OSTEOPOROSIS 12

et al (2001) identified that women are undereducated about their risks for osteoporosis and don’t

know how they can prevent it within their lifestyle choices. In addition, men aren’t educated

about osteoporosis as much as women (Ford, Bass, & Keathley, 2007). In specific, only 84% of

participants in their survey knew what osteoporosis was. Most people think that osteoporosis can

only occur in women. In specific, results of Cummings and Melton (2002) research indicated that

59% of their participants (all women) identified that osteoporosis could also affect men. Ford,

Bass, & Keathley (2007) urge that awareness education should focus attention to men and

women equally. Education efforts and social marketing helps increase public awareness about

osteoporosis (Ford, Bass, & Keathley, 2007). The Surgeon General has noted that prevention

awareness have been made towards younger populations. In specific, The Best Bones Forever

initiative has been formatted to appeal to young girls and teens (DHHS). According to Ford,

Bass, & Keathley (2007), “educating young adults on sources of calcium rich food is warranted”

(pg 46). The Surgeon General expressed that responsibility for decreasing the impacts of

osteoporosis are “public health leaders and advocates, government and nongovernmental

agencies, communities, health-care professionals, and everyone in between” (pg 369). In

addition, Geriatricians recommend education to reduce injury and increase compliance (Aspray

et al, 2006). In conclusion, the Surgeon General recommends that system based approaches

should “highlight disease education and awareness, improvement of links to resources, risk

recognition training, monitoring and evaluation of outcomes, intervention strategies, and better

preventive, diagnostic, and treatment services” (p 369). Finally, to reduce the prevalence and

impact of osteoporosis, WHO recommends (1999) that “the general public include a physically

active lifestyle, with some time regularly spent outdoors, balanced diet providing a calcium

OSTEOPOROSIS 13

intake of at least 800-1500 milligram per day in children and adults, as well as avoiding smoking

and high alcohol consumption”.

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