Osteoporosis

Osteoporosis is often referred to as a "silent" disease because it typically has no specific clinical signs or symptoms until a fracture occurs. Spine fractures can lead to:

• Severe back pain
• Loss of height
• Spine deformities, such as a stooped or hunched posture (kyphosis)

Bones affected by osteoporosis can become so fragile that fractures may occur spontaneously or due to:

• Minor falls, which generally do not cause fractures in healthy bones
• Everyday stresses, such as bending, lifting, or even coughing

Are you experiencing bone pain? It could be osteoporosis. Learn more about the risk factors to determine if you fall into that category.

Normal bone turnover involves a balance between bone resorption and bone formation processes. In postmenopausal women, the rate of bone turnover increases dramatically and remains elevated after cessation of ovarian function, leading to continuous bone loss.

Bones are strongest in early adulthood, and you slowly start losing bone from around the age of 35 years. This is a common phenomenon and occurs in everyone. However, certain risk factors may increase the risk of developing osteoporosis or heighten the likelihood of disease onset.

Osteoporosis is a multifactorial disease, where no single factor can completely account for its occurrence. The most common risk factors include:

Non-modifiable risk factors

• Family history: Studies have shown that family history is a significant risk factor for fracture, along with low bone density.
• Race: Osteoporosis is a chronic health condition affecting primarily white women.
• Advanced age: Research indicates that age is a high-risk factor for osteoporosis, as Vitamin D insufficiency and reduced calcium absorption are common in the elderly.
• Female sex: Studies suggest osteoporosis is commonly encountered in older women with no underlying risk factors. Women tend to experience an earlier onset of bone loss compared to men.
• Amenorrhea: The absence of menstruation due to low estrogen levels can lead to osteoporosis.
• Early menopause: Menopause occurring before 45 years of age, surgical removal of both ovaries, and prolonged perimenopausal absence of periods can lead to osteoporosis.
• Hormone-related disorders: Diseases that can trigger osteoporosis due to hormonal imbalances include:
  • Overactive thyroid gland
  • Reduced amounts of sex hormones (estrogen and testosterone)
  • Disorders of the pituitary gland
  • Overactivity of the parathyroid glands (hyperparathyroidism)
  • Primary and secondary hypogonadism (when sex glands produce little or no hormones) in men
• Diabetes: It can increase bone cell destruction and decrease bone formation, leading to accelerated bone loss.
• Malabsorption: This can occur due to conditions such as Coeliac disease and Crohn's disease.
• Chronic kidney disease: Studies suggest that chronic kidney disease (CKD) is associated with the development of osteoporosis and fragility fractures.
• Blood disorders: Hematological diseases like thalassemia and pernicious anemia are frequent causes of secondary osteoporosis.
• Rheumatoid arthritis (RA): This inflammatory disease is associated with osteoporosis due to active inflammation and glucocorticoids.
• Dementia: This group of symptoms affecting memory and thinking can lead to decreased activity levels and lower sunlight exposure, predisposing individuals to osteoporosis.
• Depression: Research indicates that depression is a risk factor for low bone mineral density (BMD) and fractures, especially in middle-aged women and elderly subjects of both genders.
• Cancer: Bone metastases are a common consequence of cancer, leading to decreased bone density and pathologic fractures.
• Long-term bed rest: Studies have concluded that bone loss is more evident in elderly patients advised to undergo prolonged bed rest.
• Spaceflight: Astronauts who travel in outer space tend to lose bone mass density due to microgravity, which can lead to osteoporosis.

Modifiable risk factors

• Smoking: Studies have shown a direct relationship between tobacco use and decreased bone density, making it a risk factor for osteoporosis and fractures.
• Low BMI: A low body mass index (BMI) is an important modifiable risk factor for osteoporosis and osteoporotic fracture development.
• Inadequate physical activity: A sedentary lifestyle encourages the loss of bone mass, leading to osteoporosis.
• Low dietary calcium intake: Osteoporosis is more likely to occur in individuals with low calcium intake, and a lifelong lack of calcium contributes to its development.
• Vitamin D deficiency: Vitamin D plays a crucial role in the absorption of calcium and phosphorus, and a deficiency can lead to osteoporosis.
• Alcoholism: Excessive alcohol consumption compromises bone health and increases the risk of osteoporosis by interfering with calcium balance in the body.
• Medications: Many drugs can affect bone metabolism. Medications that can cause bone loss include:
  • Heparin
  • Warfarin
  • Cyclosporine
  • Glucocorticoids
  • Medroxyprogesterone acetate
  • Cancer drugs
  • Thyroid medications

Osteoporosis may not show definite symptoms, but recurrent falls can indicate it, as osteoporosis may cause muscle weakness. The diagnosis consists of the following:

Screening and History

Older adults at higher risk of osteoporosis must be screened periodically and evaluated for fracture risk. During regular check-ups, a patient's previous history of fractures due to falls, smoking, and alcohol intake details, menopausal status, and medication history must be taken and recorded.

Physical Examination

The physical examination must include height, weight, and body mass index to determine any loss of height. A BMI less than 21 kg/m² and a loss of 5 cm or more are considered risk factors for osteoporosis. The presence of walking disorders, weakness, and postural instability increases the risk of fractures and falls.

Imaging Tests

1. Bone Mineral Density (BMD): This test provides a snapshot of bone health by estimating the amount of calcium and other minerals in bones. This is the gold standard for diagnosing osteoporosis and utilizes an x-ray, known as a DXA scan, especially in the hip and spine, to determine bone loss.

T-Scores and WHO diagnostic criteria for osteoporosis include:

• Normal: 1.0 and higher
• Osteopenia (loss of BMD): 1.0 to −2.5
• Osteoporosis: −2.5 and lower
• Severe osteoporosis: −2.5 and lower with one or more fragility fractures

Note: FRAX (Fracture Risk Assessment Tool) considers risk factors and BMD measurements to predict the probability of major osteoporotic fractures.

2. QCT: Quantitative computed tomography (QCT) is a test to measure bone mineral density using computed tomography (CT). It is generally used to measure BMD of the spine or peripheral sites.

Laboratory Tests

To determine other causes of osteoporosis, blood tests may be needed. They include:

• Calcium tests
• Vitamin D tests
• Tests for specific hormones (as discussed in risk factors)
• Biochemical markers of bone turnover

These have been used widely in clinical research and help determine the bone formation and resorption products released into the circulation. These include various bone-formation markers and bone-resorption markers.

Your genes may affect your height, weight, and bone density, but a healthy lifestyle can protect your bones. Here are a few tips to prevent osteoporosis:

• Early screening is vital: Early screening can identify the risk factors for osteoporosis, which can help you make the right lifestyle changes to prevent it.
• Bask in the sunlight: Insufficient exposure to sunlight may be associated with many disorders. Getting sufficient and healthy sunlight helps strengthen teeth and bones, which in turn helps in preventing osteoporosis.
• Optimize calcium and vitamin D intake: Calcium is essential for maintaining bone health. Vitamin D is vital for healthy bones and teeth as it aids in the absorption of calcium in the body. However, it can be hard to get enough from food alone. Consider taking vitamin D and calcium supplements.
• Stop smoking and drink alcohol in moderation: Smoking and alcohol are associated with an increased risk of osteoporosis. Quitting smoking and limiting your alcohol intake can help prevent osteoporosis.
• No excuses for not exercising: Exercises like walking, dancing, low-impact aerobics, elliptical training machines, and stair climbing work directly on the bones in your legs, hips, and lower spine and can slow mineral loss.

Learn more about 6 everyday habits that can prevent osteoporosis.

Treatment recommendations are often based on the risk of breaking a bone and slowing down the bone loss process. It consists of the following:

Non-pharmacological management

• Making specific lifestyle changes like increasing calcium and vitamin D intake
• Engaging in weight-bearing exercise
• Smoking cessation
• Limiting alcohol and caffeine consumption
• Preventing falls

Pharmacological management

The goal of pharmacological therapy is to reduce the risk of fractures. It includes medications like:

1. Antiresorptive agents: These drugs slow down the resorption of the bone. They include:
   • Bisphosphonates: These decrease bone resorption by limiting the activity of bone destruction cells. Note: Oral bisphosphonates should be administered with a full glass of water in the morning on an empty stomach 30 minutes before a meal or other medications.
   • Denosumab: This drug is used as first-line therapy for patients at high risk of fracture and for patients who are not able to use oral therapy, as denosumab is available as an injectable formulation.
2. Hormonal therapies: These use synthetic hormones to manage osteoporosis. They include:
   • Estrogen agonists/antagonists: This class of drugs is also known as selective estrogen receptor modulators (SERMs). It includes:
     • Raloxifene
     • Conjugated estrogens/bazedoxifene
   • Estrogen-progestin therapy: In osteoporotic management, estrogen therapy is FDA-approved only for the prevention of osteoporosis in high-risk postmenopausal women.
   • Testosterone therapy: This therapy is recommended for those for whom antiosteoporotic treatment is contraindicated, whose testosterone levels are less than 200 mg/dL, or those at borderline high risk for fracture.
   • Calcitonin: It is a synthetic polypeptide hormone with properties similar to natural calcitonin. It is FDA-approved treatment for osteoporosis in women who have been postmenopausal for more than five years when alternative therapies are not feasible.
   • Parathyroid hormone analogues: These are synthetic forms of parathyroid hormones used to treat osteoporosis. Drugs include:
     • Teriparatide
     • Abaloparatide
3. Newer drugs: These include:
   • Romosozumab
   • Odanacatib
   • Lasofoxifene

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The best home remedies to reduce the risk of osteoporosis and strengthen bones include eating foods rich in calcium and Vitamin D. These include:

• Milk: A rich source of calcium and vitamin D, essential nutrients for bone growth and development.
• Apple cider vinegar: Abundant in nutrients like calcium, potassium, and magnesium, which can enhance bone health.
• Cheese: Studies suggest that cheese, especially Parmesan, is excellent for bone health and osteoporosis prevention.
• Eggs: Research indicates that whole eggs can help prevent osteoporosis and reduce the risk of fractures in the elderly.
• Fish: Fatty varieties such as salmon, mackerel, tuna, and sardines are rich in Vitamin D and beneficial for individuals with osteoporosis.
• Citrus fruits: Fruits rich in Vitamin C, like oranges, can aid your body in producing what it needs for strong bones.
• Green leafy vegetables: Dark leafy greens like Chinese cabbage, kale, and turnip greens are rich sources of calcium.
• Sesame (Til): Contains copper, calcium, manganese, magnesium, and selenium, making it ideal for individuals with calcium deficiencies.
• Soy: Soy sprouts contain coumestrol (a potent phytoestrogen) that can decrease the risk of osteoporosis by increasing estrogen levels.

If osteoporosis is detected early and treated, the outcomes are good. However, if the condition remains untreated, it can lead to chronic pain and fractures. Complications of osteoporosis include:

• Recurrent falls: Studies show that individuals with osteoporosis have a higher risk of falls due to muscle weakness, spinal kyphosis, or decreased postural control.
• Pathological fractures: These are the most severe complications of osteoporosis, particularly in the hip or spinal column.
• Hip fractures: Often resulting from falls, these can lead to disability and an increased mortality risk in the first year following the injury.
• Vertebral fractures: These can cause kyphosis (hunchback), chronic pain, respiratory issues, and a high risk of developing pneumonia.

The main aim of alternative therapies is to work with conventional treatment to provide relief. Always talk to your doctor before starting anything new. Alternative therapies that work best for osteoporosis include:

• Massage therapy: Massages can alleviate symptoms of osteoporosis, such as pain and swelling, by relaxing your muscles. According to a study, receiving a massage, particularly Thai massage, can significantly help increase bone formation.
• Acupuncture: Acupuncture is a therapy used in traditional Chinese medicine that involves placing very thin needles at strategic points on the body. Studies show that acupuncture could be an effective therapy for treating osteoporosis as it promotes healing.
• Tai chi: Tai chi improves muscle strength and coordination and reduces muscle or joint pain and stiffness. This ancient Chinese practice uses a series of body postures that flow smoothly and gently from one to the next. However, there is a need for precise data on the effectiveness of Tai chi for osteoporosis.
• Melatonin therapy: Melatonin is a hormone produced by the brain that is responsible for sleep. Studies have demonstrated that melatonin supplementation can improve perimenopausal and age-related osteoporosis and help prevent bone loss.

You can lead an active and fulfilling life even if you have osteoporosis. All you need to do is make specific lifestyle changes. Tips that can help you if you are living with osteoporosis include:

Prevent Falls

The major complication of osteoporosis is fracturing due to falls. Things to keep in mind to prevent falls include:

• Wear shoes with non-slip bottoms
• Ensure there is nothing slippery on the floor
• Always use grab bars in the bathrooms and railings on stairs
• Avoid throw rugs and loose wires and cords
• Keep the lighting bright for better visibility

Use Hip Protectors

This is a different approach to the prevention of hip fractures. Hip protectors are rigid inserts used to prevent direct trauma to the hip. They can be particularly helpful for the bedridden elderly population.

Take Extra Care of Broken Bones

Fractures usually take 6 to 8 weeks to heal, and osteoporosis does not affect the healing duration. Recovery depends on the type of fracture; while some fractures heal efficiently, others may require more intervention.

Note: You may need a physiotherapist's help to recover as much as possible.

Manage Your Pain

Pain is subjective and varies for each individual. Ways to manage pain include:

• Take pain medications
• Try warm baths or hot packs and cold packs
• Opt for relaxation techniques and hypnosis