Osteoporosis: A focus on prevention

Community Medicine-0616401

Prepared by
Isaac Yaqoub Derbashi 21210486
Anan Fawwaz Bseiso 21211330

Instructor
Dr.Asaad Ramlawi

Al-Quds University
Jerusalem , Palestine

2016
Introduction:
Osteoporosis is a disease that affects more than 200 million of people around
the world. It is a condition characterized by reduced bone mass density and
microarchitectural deterioration of bone tissue, leading to increased bone
fragility and consequent increase in fracture risk, resulting in skeletal
fractures following minimal trauma.
Fragility fractures, the most devastating aspect of osteoporosis, are a major
cause of morbidity and disability in the elderly and, in the case of hip
fractures, can lead to premature death. These fractures most commonly
occur at the wrist, shoulder, spine, and hip, although they can occur
throughout the skeleton.

Epidemiology and financial burden of osteoporosis

Worldwide, more than 200 million have osteoporosis. Because osteoporosis is
an age-related condition, it's known to be the most common cause of
fractures in elderly. Its estimated that by the age of 80 years, 70% of women
are osteoporotic at the hip, lumbar spine or distal forearm. In the developed
world, 2% to 8% of males and 9% to 38% of females are osteoporotic.
The lifetime risk for a wrist, hip or vertebral fracture is estimated about 30 to
40% in developed countries, equivalent to the risk for coronary heart
disease. According to WHO, osteoporosis causes about 8.9 million fractures
each year worldwide , of which more than half of these fractures occur in the
Americas and Europe.
Osteoporotic fractures take a huge personal and economic toll worldwide
because of the associated morbidity, mortality and costs. It's estimated that
EU spends 37 billion per year on osteoporosis-related health care- out of
which: costs of treating incident fractures represented 66%, pharmacological
prevention 5% and Long-term fracture care 29%. The financial burden of
osteoporotic fractures includes indirect costs (morbidity, loss of working
days) and direct costs (hospital acute care, in-hospital rehabilitation,
outpatient services, long term nursing care). also, some costs are difficult to
quantify, e.g. deterioration of quality of life, and time spent by the family on
the care of the patient.

Risk Factors
There are many factors that increase the risk of osteoporosis, some of these
factors are non-modifiable and others are modifiable, modifiable risk factors
are the target of our prevention strategy:
-Age: Osteoporosis becomes more common as people get older. Peak bone
mass is achieved by the age of 30-35 and then starts to decline. The higher
the peak mass, the less likely to be diagnosed with osteoporosis later in life.
-Genetics: a person with a family history of a hip fracture is at increased risk
of osteoporosis. At least 30 genes are currently known to be associated with
the development of osteoporosis. Moreover, osteoporosis tends to cluster in
families and curtain ethnic groups.
-Hormones: Females are at a higher risk of osteoporosis. In the developed
world, 2% to 8% of males and 9% to 38% of females are affected. Estrogen
deficiency following menopause or surgical menopause is associated with an
accelerated loss of bone mineral density, while in men, any condition that
cause decrease in testosterone levels has a comparable effect.
-Certain medications: the use of some drugs is correlated with the
development of osteoporosis. Especially steroids (often called Steroidinduced osteoporosis (SIOP)) and anticonvulsants. Other drugs are lithium,
proton pump inhibitors, some anticoagulants and chemotherapeutic agents.
-Medical conditions: Many diseases and medical conditions have been
associated with osteoporosis, examples are Endocrine disorders: diabetes
mellitus, hyperparathyroidism, hyper/hypothyroidism, and Cushing's
syndrome. Hematologic disorders: multiple myeloma, thalassemia,
leukemia, lymphoma hemophilia and sickle-cell disease. Gastrointestinal
disorders: Celiac disease, inflammatory bowel disease (IBD) and pancreatic
disease. Other disorders are hypogonadal states and rheumatologic
disorders.
-Life style: dietary and lifestyle factors can have a direct effect on bone
density or by altering the calcium levels, these factors include: excess
consumption of alcohol, tobacco smoking (both active and passive), low
calcium intake, high protein intake, excess vitamin A, vitamin D deficiency
and physical inactivity.

Prevention of Osteoporosis

Prevention of osteoporosis focuses on lifestyle and dietary factors mentioned

above, this can be done by increasing the awareness of modifiable risk
factors through education for the general population. These changes aim to
achieve maximum peak bone mass and maintain that mass as long as
possible.
Adequate Calcium intake
Calcium is one of the main bone-forming minerals, and an adequate intake is
necessary to supply bone at all stages of life. When calcium intake is
inadequate, the body has to reabsorb calcium from bone to maintain a
constant serum level, reducing the bone density and making it more
osteoporotic.
How to get enough calcium? Dairy products are the best source for
calcium, as it's more easily absorbed from these products. Other calcium-rich
foods are orange juice, cereals, bread and calcium-fortified drinks.
Adequate vitamin D intake
Vitamin D promotes calcium absorption in the intestines and maintains
adequate serum calcium and phosphate concentrations, which is important
for acquisition and maintenance of bone mass. Vitamin D can be obtained
either from the diet or by synthesis in the skin under the action of sunlight.
Vitamin d deficiency is more prevalent in certain groups:

Dark-skinned people.
People unable to obtain sunlight exposure.
Medically immobilized people.
Elderly people in residential care.

-For these groups, vitamin D supplements should be considered.

How to get enough vitamin D? Vitamin D can be obtained from diet in
small amounts, examples are oily fish (like sardines and canned tuna),
fortified milk, eggs and certain types of mushrooms, but adequate intake
usually can't be achieved by diet alone.
So, adequate sun exposure is required to get enough vitamin D amounts,
people need to expose their face and arms to the sunlight for about 15-20
minutes every day. Dark-skinned people require 3 to 4 times more exposure
to gain the same benefit.

Calcium and vitamin D dietary recommendations:

Life Stage Group

1 - 3 years old
4 - 8 years old
9 - 13 years old
14 - 18 years old
19 - 30 years old
31 - 50 years old
51 - 70 years old
51 - 70 year old
females
71+ years old
14 - 18 years old,
pregnant/lactating
19 - 50 years old,
pregnant/lactating

Calcium Recommended
Dietary Allowance
(mg/day)
700
1000
1300
1300
1000
1000
1000
1200

Vitamin D
Recommended Dietary
Allowance (IU/day)
400
600
600
600
600
600
600
600

1200
1300

800
600

1000

600

Regular exercise
Regular weight-bearing activities such as running, stair-climbing, walking
dancing and jumping provide high impact necessary for bone health. Bone
adapts to this type of exercise by increasing bone mineral density (BMD)
especially in childhood and adolescence. This occurs due to the combined
osteogenic stimuli of ground impact forces and muscle pull. Moreover,
weight-bearing exercise may help prevent falls by improving strength, agility
and balance.
Smoking cessation
Studies have associated smoking with low bone density. Although the exact
mechanism is not very clear, it's suggested that smoking breaks down
estrogen, and lowers body weight, making bone more osteoporotic. Smoking
is independent of confounding factors and it's cessation is recommended.
Alcohol

Most publications report that drinking more than three drinks daily is
detrimental to bone density. Like smoking, the exact mechanism is not wellknown.
Preventing fractures
The consequences of osteoporotic fracture can be devastating, for example
hip fracture can cause 10-20% excess mortality within 1 year and 2.5
increase in the risk of future fractures.
The focus for preventing fractures is to:

Preventing falls: this can be achieved by regular vision and hearing

tests, home safety and exercise program.
Osteoporosis detection: A clinical diagnosis can be made in at-risk
individuals. An X-ray can indicate low bone density. However, the gold
standard for diagnosis is bone densitometry (DEXA).
Pharmacological intervention: Calcium supplements when intake is
inadequate, and vitamin D supplements for people who are deficient.
also, there is an evidence that bisphosphonates reduce the risk for
fractures, so they can be used in high risk people. However, adequate
calcium and vitamin D levels are prerequisites for bisphosphonates
therapy.

References:
1- Ann Prentice; Diet, nutrition and the prevention of osteoporosis. Public
Health Nutrition: 7(1A), 227243
2-National Osteoporosis Foundation, Clinician's guide to prevention and
treatment of Osteoporosis 2008, Available at: www.nof.org
3-Orsini LS, Rousculp MD, Long SR, Wang S (2005). Health care utilization
and expenditures in the United States: a study of osteoporosis-related
fractures. Osteoporosis Int. 16:359-371.

4-Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A

(2007). Incidence and economic burden of osteoporosis-related fractures in
the EU,2005-2025. J Bone Miner Res 22:465-475.