Kathryn Jean Lucas, MD
611 N 35th St
Morehead City, North Carolina 28557

Osteoporosis Information

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BONING UP ON OSTEOPOROSIS

By: K. Jean Lucas, M.D.

What is Osteoporosis?

Osteoporosis, a term literally meaning "porous bone", is the loss of so much of the mineral content of the bone in the body that even the slightest injury or a daily activity may cause a fracture. Bone loss occurs rapidly during the onset of and for approximately 5 years after menopause. Bone is also lost gradually as people get older. A wide variety of medical disorders and medications may also increase bone loss throughout life.

Osteoporosis, a major public health concern, affects more than 20 million people in the United State. Among those who live to be 90 years old, 32% of the women and 17% of the men will have a hip fracture. Osteoporosis is responsible for 1.3 million spine and hip fractures per year. Complications of fractures caused by osteoporosis are the 12th leading cause of death in the U.S.

The Ever-Changing Bones

Despite the idea that the skeleton is a rigid structure that does not change, the bones of the body are constantly remodeling. Part of this process is done to keep the levels of calcium stable in the bloodstream, but also the bones are constantly repairing and strengthening themselves in response to minor damage and outside forces such as exercise. Bone reaches its peak mass at age 35; after that age, bone strength and weight may be gradually lost as we age. The stronger the bones are as they mature, the less an effect aging will have on them.

Until age 35, you build and store calcium in your bones easily. Your intestine absorbs calcium more efficiently as well. With aging, the calcium from your bones is lost at a faster rate than it is added. Especially around menopause, bone mass may drastically decrease because of the loss of estrogen.

Who is at risk for developing osteoporosis?

	Caucasian, Asian females > Black females (African Americans have 10% more bone mass on average than Caucasians and have 50% less fractures)
	Early or surgically induced menopause
	Low calcium intake throughout life (the amount of calcium you take in from teenage years to age 35 is extremely important in determining how strong your bones will be as you age.)
	Lactose intolerance (may cause avoidance of calcium rich dairy products)
	Positive family history of osteoporosis
	Small frame and low weight during bone forming years (these people have lower bone mass to start with)
	Cigarette smoking (has a direct effect on the bone, causes earlier menopause, and lessens the effectiveness of estrogen replacement)
	Lack of physical activity or immobilization (prolonged bed rest causes rapid bone loss while weight-bearing exercise reduces bone loss)
	Excessive alcohol intake (has a direct effect on the bone and predisposes to falls which may result in fractures)
	Older > younger
	Women > men (women have four times the risk of osteoporosis than men. They have less bone mass to start with, lose bone rapidly at menopause and live longer)
	Hyperthyroidism: either by your own body producing too much thyroid hormone or your taking too much thyroid hormone replacement (as indicated by a lower than normal TSH)
	Taking cortisone, steroids, (cause loss of calcium rapidly from the body as well as impair the absorption of calcium from the diet) or anticonvulsants (affect the absorption of calcium by interfering with the action of vitamin D)
	Hyperparathyroidism (causes the loss of calcium from the bones leading to an elevation of the calcium level measured in the blood)
	Eating disorders or any type of prolonged malnutrition (may cause loss of weight, low calcium intake especially in the crucial teenage years, and low estrogen levels leading to periods stopping)

How can bone loss be prevented?

	Adequate calcium intake through life (1000-1500 mg/day of elemental calcium)
	Maintain normal body weight and do regular physical exercise
	Take estrogens starting at the time of menopause or at any time after menopause. Estrogens decrease bone loss no matter at what age they are started.
	If estrogens contraindicated, other drugs (alendronate, calcitonin) may improve bone density
	Stop smoking
	Lower alcohol intake
	Be aware of risk factors listed above which may affect you in order to make lifestyle modifications

Getting adequate calcium

calcium is the major component of bones and teeth. If you have had kidney stones, you should check with your doctor before starting calcium supplementation. Calcium kidney stones may be a sign that you are losing too much calcium through your kidneys. Medical evaluation is needed for treatment of this situation.

How do I increase my calcium intake?

Food sources: increase calcium without increasing fat content of the food. Examples are as follows:

	Skim milk:	300mg/cup				Mozzarella cheese:	207mg/oz
	Ricotta cheese:	337mg/ 2 cup				Yogurt, low fat:	415mg/cup of plain
	Yogurt, low fat:	345mg/ cup of fruit				Calcium enriched orange juice:	250mg/ cup
	Salmon with bones:	167mg/ 3oz				Vanilla ice milk:	176mg/cup
	Collard greens:	179mg/ one-half cup				Kale	90mg/ 1/2cup
	Turnip greens	249mg/cup				Broccoli, cooked	177mg/cup
	Soybeans	131mg/cup				Oysters, fresh	426mg/lb.
	Tofu	145mg/4 oz.				Almonds	132mg/2 oz.
	Orange	52mg/one medium

Tips to increase calcium content in cooking:

1. Add nonfat dry milk to soups, casseroles, gravies (1 tsp. provides 50 mg. calcium).
2. In baking, add 1/4 cup nonfat dry milk to cakes, cookies, muffins and breads. This amount will not alter the product and adds about 200 mg. of calcium.
3. In salads, use dark green lettuces such as Romaine and Endive which have a higher calcium content than Iceberg lettuce.
4. Add cheese sauces to vegetables. Keep fat calories down by using evaporated skim milk and low fat cheeses.
5. Use grated Parmesan cheese to season vegetables and popcorn.

Avoid excessive protein

An excessively high protein intake will increase calcium loss through the urine. A daily intake of two 3 ounce portions of lean meat or fish is an adequate protein intake for women. If three or four glasses of milk are consumed daily, protein from other sources should be decreased.

Oxalates and phytates

These substances, which are present in whole grain cereals and dark green leafy vegetables (such as spinach), block calcium absorption. The calcium in these foods is not available to the body because it is bound to oxalates or phytates.

Maximizing the effectiveness of calcium supplements:

	To test the ability of your calcium supplement to be absorbed in your stomach, the supplement should be placed in a glass of vinegar for 15 minutes. If the calcium completely dissolves in the vinegar, then it will dissolve in your stomach. Do not drink the vinegar. This is only a test. (this test does not apply to and should not be used in chewable forms)
	Calcium supplements should be taken with meals, at most 500mg at one time
	Orange juice will increase absorption of calcium
	Avoid taking calcium with high fiber meals or bulk laxatives such as Metamucil
	Drink plenty of fluids if taking a supplement
	Do not take iron supplements with calcium since they will decrease the absorption of each other

Vitamin D

Take a multivitamin with 400 IU of Vitamin D. (Vitamin D allows calcium to be absorbed by the body.) Vitamin D is made in the skin after exposure to sunlight. Sunscreens will block the formation of vitamin D by the skin. Too much vitamin D is harmful because it accumulates in the body. The usual dose in multi-vitamins is the safe dose of 400 IU per day. People with vitamin D deficiency may require a higher dose or a different form of vitamin D prescribed by their physician. These patients require careful monitoring of their blood calcium.

Signs and Symptoms of Osteoporosis

Osteoporosis is a silent disease until the bone mass is so low that fractures occur. No warning signs may occur at the very early stages. Since prevention is much more effective than treatment, each individual should be aware of her/his risk of getting osteoporosis.

The first signs of osteoporosis may be:

	Loss of height as aging occurs
	Loss of bone on regular x-rays ( as much as 30% of the bone is already lost by the time it shows up on the film)
	Humping over of the upper spine (dowager’s hump)
	Fractures with minimal trauma (may occur with routine activities such as bending, lifting, or rising from a chair)
	Low bone density measured on a bone densitometer

How to measure bone density

A bone density exam is an excellent test to determine the actual density or thickness of your bones. It requires less than one-tenth the amount of radiation that is required by a chest x-ray. As with any medical procedure, be sure to inform your physician if you are or could be pregnant.

The bone density exam is a simple, painless, noninvasive procedure. You will be asked to lie perfectly still on a table while a mechanical arm with x-ray passes over the area to be tested (for example, arms, spine, or hips). A detailed computer analysis of your results is then performed. The procedure lasts approximately 20-30 minutes.

A bone density report will show the percentage of bone you have compared with peak bone mass (which usually occurs around age 35). This "Z-score" assumes that everyone has 100% bone mass at the peak bone mass years. Individually, one may have had a different total bone mass, either greater or less than the 100%; however, since bone density tests are not done during the peak bone mass years, one cannot be accurately compared to oneself, but only to a population of the age of peak bone mass. Another comparison is to members of your own age group. This comparison is helpful in someone with a higher degree of bone loss than normal to determine if another cause for the osteoporosis exists.

Preventing fractures

As people age, not only do the bones get weaker, but coordination may decrease, vision and hearing may become impaired, and medication may be given which can cause dizziness, unsteadiness, or sedation.

If you have osteoporosis, you should do as much as possible to prevent falling by:

1.

Having your hearing and vision checked yearly and corrected.

2.

Fall-proof your home: Floors: remove all throw rugs or firmly attach them to the floor. Remove loose cords. Minimize clutter Stairs: should be well-lighted, have handrails on both sides. Be sure to use the handrails going up and downstairs Bathrooms: no-skid flooring, install grab bars in the bathtub and use non-skid tape in the tub. Kitchen: do not put supplies out of reach, avoid bending over, wipe up spills immediately, use sturdy stool or the help of a tall person to reach higher places Bedrooms: light switch and phones should be in reach of the bed to prevent having to get up at night Nightlights should be in all areas adjacent to bedroom in order to see where you are going if you do have to get up at night Furniture should be out of the way you usually walk through a room, especially low furniture such as coffee tables Couches and chairs should be of proper height and not too soft so that one can stand up from them without difficulty. Watch out for pets running under foot When driving, wear seat belts, adjust the seat properly, use lumbar support if available, and use the head rest properly. Avoid high heels. Wear flat, comfortable shoes. Lower intake of alcohol. Avoid sedating drugs or drugs that may cause dizziness. Examples of these medications are: tricyclic anti-depressants, blood pressure medications, sleeping pills, and tranquilizers. Ask your physician if you are on of these medications.

Precautions regarding movement for those with osteoporosis

	Do not bend from the waist down. Bend knees in order to pick up or lift an object. By doing the motion this way, you avoid additional force on your back.
	Do not do sit ups that involve raising shoulders off the floor
	Avoid twisting motions of the back. Turn the whole body around in order to see something behind you.
	Practice good posture: head up, back straight, abdomen in , buttocks under
	Support back with hand when coughing or sneezing.
	Avoid excessive pushing or pulling. Use a rocking motion of your feet to move objects ahead or back
	When sitting for prolonged periods of time, use a rolled up towel or back support behind your lower back
	When standing for any length of time, put one foot up on a step stool and change position of feet periodically
	Keep feet apart to help balance when you are bending from the knees
	When you get out of bed, roll over to one side, use your arm to push up from the bed, sit on the edge of the bed for a few minutes before getting up

The role of exercise in the treatment of osteoporosis

In general, exercise decreases bone loss and stimulates bone formation. Tennis players have a higher bone mass in their playing arm than in the other one. Pushing exercises using the forearm increase the bone mass of the pushing arm. Weight lifting increases the bone of the arm doing the work. Walking, stair climbing and other weight bearing exercises increase the bone mass of the spine and pelvis. Exercise also builds muscle strength and coordination which helps avoid falls or injury when falling.

Precautions when starting exercises

	Check with your physicians before starting
	Start slowly with only a few repetitions
	Avoid injuries, stop if in pain
	Use comfortable, well-padded shoes to exercise in

Examples of exercises

Formal physical training to optimize bone building and strength and decrease injury risk are available.

General weight bearing: walking, stair climbing, low impact aerobics

Back exercises

Lay on your stomach, arms at the sides. Slowly raise your shoulders off the floor. Back stretches and squats also improve the low back strength.

Wrist exercises

Use 1-3 pound weights. One arm at a time with elbow bent and supported on knee, flex wrist with weight up. Repeat with other arm

Hip Exercises

Stand next to a wall, use arm next to wall as support, Raise leg opposite to wall up as far as it will go comfortably to the side and then to the back. Repeat with the body facing the opposite direction using the other leg.

Squats: Use a bar (broomstick, yardstick) across back of shoulders, holding it with your hands. Keep head up, back slightly arched, squat slowly until upper thighs are at a 45 degree angle to the floor.

Medications used to treat osteoporosis

• Estrogen: Women on estrogen have a 50% decrease in fractures as they age. The most effective time to start estrogen is during early menopause when the estrogen levels begin to drop. This will stop the rapid loss of bone which occurs during menopause. Estrogen is effective at any age to prevent bone loss but the earlier it is started the better. Progesterone is added to prevent cancer of the uterus in women who have not had a hysterectomy. Some patients cannot take estrogen. For example, women with breast cancer cannot take estrogen but can take tamoxifen, an estrogen like compound which also protects bone. Future studies on women with breast cancer are reexamining these issues.
• Alendronate (Fosamax): This medication was recently approved by the FDA for the treatment of osteoporosis. It binds to the calcium crystals in the bone, prevents bone loss, and increases bone mass. It needs to be taken in the morning on an empty stomach with a large glass of water. Because it has a tendency to irritate the esophagus, one should sit up to take it and not lay back down. The water is also important to wash the tablet down. No coffee or other drinks or medications should be given at the same time.
• Calcitonin: Previously this medication was available by injection only, now it is supplied nasal spray form. It prevents some bone loss and may help with the pain of a new fracture. It may also prevent bone loss induced by cortisone preparations. The nasal spray has less side-effects than the injections.
• Fluoride: This medication is still very experimental. In some studies, bone mass has been shown to improve in the spine but not the hips. Fracture rates have not consistently been shown to decrease. Further studies will be needed in order to see what if any fluoride has.
• Calcitriol: This medication is a special form of vitamin D and is used in only selected cases. It is used in kidney disease, vitamin D deficiency and hypoparathyroidism.
• Calcium: This mineral is very important in providing the substrate needed to build bone. With any of the above medications, taking 1200-1500mg/day requirement is very important.

For more information on osteoporosis and its treatment, consult your physician or contact:

The National Osteoporosis Foundation 1232 22nd Street N.W. Washington, D.C. 20037-1292 202-223-2226

Send mail to Seth.Medlin@BeachDoctor.com with questions or comments about this web site.
Send mail to Dr. Lucas lucas@BeachDoctor.com
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