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Osteoporosis: stopping the silent thief!

Raymond Lepage, PhD
Raymond Lepage, PhD
Senior Scientific Advisor

Most people are sensitive to bone health only during moments like childhood and pregnancy. All parents and future parents are aware that building strong bones with calcium and vitamin D is very important for the foetus or a child. After the growth years, we seem to think that our solid skeleton is there forever. It is only after many decades — 50 years in men and post-menopause in women — that we realize that during all these years a silent thief was slowly but relentlessly stealing precious bone material.

What is osteoporosis?

An abnormally low bone mass defines osteoporosis, a disease affecting 2 million Canadians. According to Osteoporosis Canada, one-third of all women and one-fifth of all men will break a hip, spine, wrist, or shoulder due to osteoporosis during their lifetime [1]. These fractures represent 80% of all fractures occurring in women and are more common in menopausal women than the combined rate of heart attack, stroke, and breast cancer. In the year after experiencing a hip fracture, risk for death increases by 33% in men and 20% in women, with this risk continuing to persist albeit at a lower level for 10 years [2]. These figures should convince everyone of the importance of keeping healthy bones.

Causes

  • decline of estrogen production [3];
  • poor diet;
  • low exercise;
  • medications;
  • various diseases including parathyroid and thyroid gland hyperactivity;
  • intestinal malabsorption (celiac disease, chronic inflammatory bowel disease)
  • renal disorders [4].

Risk factors

If menopause or a significant loss in height are relatively evident reasons to consult a physician concerning osteoporosis, many other factors contribute to the overall risk of developing the disease in the following years.

  • gender
  • age
  • dietary calcium and vitamin D intake
  • physical activity
  • alcohol and tobacco use
  • family history of osteoporosis or bone fracture
  • personal history of bone fracture following a simple bump
  • tendency to fall
  • many drugs and illnesses

Osteoporosis Canada provides an online quiz that may help you establish your own risk level. They also provide a convenient calcium-intake calculator to help you check if your calcium intake is appropriate.

Diagnosis

Bone mineral density (BMD) measurement

Osteoporosis can be prevented and successfully treated, but like many other diseases, the sooner you start treatment, the better. In the absence of fragility fractures, the diagnosis of osteoporosis is almost completely based on a measurement of bone mineral density (BMD), also called bone density scan. This measurement can be done with a number of measuring devices, but dual energy x-ray absorption (DXA) by the spine and hip is the most common. Since 1994, osteoporosis is classified by comparing a patient’s BMD to that of a young-adult reference population. Results are expressed as a “T-score” and a T-score equal or less than -2,5 (minus 2,5) is strongly suggestive of osteoporosis. A T-score between -1.0 (minus 1.0) and -2.5 is classified as osteopenia (low bone mass) while a result higher than -1.0 is normal.

Read more: What is a bone density scan?

Blood tests

Blood calcium level is generally normal even in severe osteoporosis, and combined with Vitamin D level is most useful in detecting other bone diseases.

Other blood tests can be used to pinpoint causes of osteoporosis:

  • evaluation of estrogen (women) and testosterone (men) production;
  • thyroid and parathyroid gland function;
  • evaluation of kidney function;
  • evaluation of intestinal malabsorption;
  • protein electrophoresis;
  • levels of alkaline phosphatase (a bone enzyme);
  • urinary calcium level.

Esoteric blood tests that can directly measure protein fragments resorbed from bones (C-telopeptides, P1NP, etc.) are also available but they are mostly useful to measure the effect of different medications on bone mass.

Treatment

Bone demineralization (resorption) is a normal physiological component of aging, a process that cannot be cured. Osteoporosis is an exaggeration of this physiological process that can be slowed down. The treatment of osteoporosis consists of preventing or slowing bone loss and reducing the risk of fracture. A number of approaches, including drugs, are available to do that. Treatment of osteoporosis is slightly different in post-menopausal women compared to premenopausal women and men.

Change in lifestyle habits

All treatments begin by changing lifestyle habits:

  • taking enough calcium and vitamin D;
  • exercising;
  • quitting smoking;
  • lowering alcohol consumption;
  • reducing the use of glucocorticoids;
  • preventing falls.

Hormone therapy

In post-menopausal women where osteoporosis is caused by a fall in estrogen level, hormone therapy with estrogen alone or estrogen/progesterone combination will effectively increase bone density, reduce risk fracture and help control undesired menopausal symptoms (hot flushes). Selective estrogen receptor modulators (SERMs) also called “designer estrogens” can also be used. In premenopausal women and men, a first line of treatment will be to correct the underlying cause; low testosterone level in men, intestinal malabsorption, thyroid or parathyroid disorders in all groups.

The second part of treatment consists of administering a drug from the bisphosphonate family (alendronate, etidronate, etc.). Bisphosphonates act like a protective coating on the bone surface against osteoclasts, a group of cells that can cause the breakdown of bone tissue. Depending on the drug the oral treatment can be daily, weekly, or monthly. Specific instructions (time of the day, not to be taken at the same time as calcium supplements, staying upright for at least 30 minutes following ingestion and until after the first meal of the day) must be followed carefully.

Zolendronic acid

There is an alternative yearly intravenous treatment with zolendronic acid that requires infusion by certified medical personnel. For more severe cases, other drugs like denosumab (Prolia) and teriparatide (Forteo) can be used.

Success of treatment is generally confirmed after one or two years by a repeat measurement of the bone mineral density. However, some blood tests (C-telopeptides, P1NP) can confirm drug effectiveness and/or patient compliance within three to six months of beginning therapy.

Read more: Myths and facts surrounding Osteoporosis

Tips to prevent osteoporosis

The silent thief can be seriously slowed down long before a significant risk of fracture appears that will require the use of expensive drugs.

The already described changes of lifestyle that constitute the first part of osteoporosis treatment are also at the basis of osteoporosis prevention:

  • Ingest enough calcium (almond, soy, beans, dairy products, peas, fish, orange, meat, broccoli);
  • If needed, consider adding calcium and Vitamin D supplements;
  • Exercise daily (2.5 hours per week);
  • Stop smoking;
  • Use alcohol moderately.

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  1. “About The Disease.” Osteoporosis Canada. Consulted on November 7, 2019. https://osteoporosis.ca/about-the-disease/.
  2. “Persistence of Excess Mortality Following Individual Nonhip Fractures: A Relative Survival Analysis. ” Journal of Clinical Endocrinology & Metabolism. Consulted on November 7, 2019. https://academic.oup.com/jcem/article/103/9/3205/4996518.
  3. “Osteoporosis Causes.” Endocrine Web. Consulted on November 7, 2019. https://www.endocrineweb.com/conditions/osteoporosis/osteoporosis-causes.
  4. “Quelle est l’origine de l’ostéoporose?” L’ostéoporose, ce n’est pas drôle – commencer dès aujourd’hui. Consulted on November 7, 2019. http://www.prevention-osteoporose.ch/quelle-est-lorigine-de-losteoporose.html.