What is Osteoporosis?

Reversible factors:
Smoking and excess alcohol are associated with a decreased bone mass and increased risk of fracture.(2) Poor calcium intake has a detrimental role on developing bone. Sun exposed skin allows for the production of active vitamin D in the body. Active vitamin D allows the body to absorb calcium and be utilized effectively. Therefore, lack of sunlight or inadequate intake of vitamin D can lead to bone breakdown.

Non-Reversible factors:
African American women generally have a lower risk of osteoporosis than white women and Asian women. Women have a much higher rate of osteoporosis compared to men, presumably because of a higher bone density and slower rate of bone loss compared to women. There are many medical conditions and medications associated with bone loss and increased risk of osteoporosis. Examples include:

• Thyroid disorders (hyperthyroidism)
• Diabetes
• Parathyroid disorders (hyperparathyroidism)
• Depression
• Inflammatory bowel disease
• Alcoholism
• Liver disease
• Leukemia
• Chronic kidney disease Cushing's disease
• Eating disorders
• Early menopause (including surgical or related to chemotherapy)

Common medications implicated in causing bone loss and subsequent osteoporosis include:

• Glucocorticoids ('cortisone type medications')
• Heparin
• Certain endometriosis treatments
• Anti-seizure treatments, such as phenytoin and carbamazepine
• Excess thyroid medication
• Certain transplant medications

How is Osteoporosis Diagnosed?
Diagnosis of osteoporosis requires a high index of suspicion with knowledge of risk factors. Evaluating osteoporosis includes evaluating the density of bones at risk for fracture, including the spine and hip. Bone density testing has allowed for the early detection of osteoporosis and treatment strategies before a fracture occurs. DEXA (dual energy x-ray absorptiometry) and CT bone density testing are commonly used as a test for diagnosing osteoporosis. These tests calculate the bone mineral density (BMD) of the measured bone. The World Health Organization has defined osteoporosis according to the BMD. The diagnosis is based upon a 'T-score', which is the comparison of a persons BMD with a matched person at peak bone density (age 20-40). Osteoporosis is defined as a T-score greater than 2.5 standard deviations below peak bone density, which correlates to an increased risk of fracture due to bone fragility.

Current recommendations for BMD testing include:

• Women over age 65
• menopausal women trying to decide whether to use osteoporosis preventing medications, including hormone replacement therapy
• women with a strong family history of osteoporotic fractures
• chronic use of glucocorticoid medications
• patients with diseases that can cause osteoporosis
• patients with x-rays consistent with bone thinning ('osteopenia')

Occasionally, testing for breakdown products of bone can guide therapy of osteoporosis. Urine biochemical testing of bone breakdown products called 'N-telopeptides' can guide therapy and insure adequate dosing of medications.

What is the Treatment for Osteoporosis?
Bone quantity, quality and strength will help determine a women's risk of osteoporosis associated fractures. Earlier treatments of osteoporosis centered on increasing bone quantity. Newer treatments have focussed on diminishing the rate of bone turnover by decreasing the resorption of bone. The latest treatment theories center on improving bone quality to decrease fracture risk, despite lack of large increases in bone quantity.

Prevention versus treatment
Osteoporosis is often thought of as "a pediatric disease with a geriatric outcome"according to osteoporosis expert, Robert P. Heaney, M.D., F.A.C.P., F.A.I.N. Whenever a disease process can be prevented, significant suffering can be alleviated. Osteoporosis can be prevented by a number of considerations. Attaining peak bone mass during early adulthood through proper exercise and diet is tantamount. Adequate calcium intake is vital to assure sufficient bone quantity, quality, and strength. Altering reversible risk factors is also key to osteoporosis prevention. In menopause, weight bearing exercise for 22 month resulted in a 6.1% increase in bone density of the lumbar spine.(3) Patients with osteoporosis or at risk for decreased bone mass should avoid forward bending (flexion) and excess twisting of the spine. Examples of flexion exercises include sit-ups and toe touches. This type of movement may lead to the generation of large amounts of forces on the anterior vertebral bodies and lead to compression fractures. Therefore, extension exercises are preferred and associated with 16% vertebral fracture rate compared to 89% in postmenopausal women with osteoporosis performing flexion exercises.(4) The main goal of exercising in osteoporosis involves focussing on at-risk areas, such as the spine, hips and wrists. These exercises should be performed 3-5 times per week. Weight bearing exercises such as walking, dancing, stair climbing and hiking are helpful. Resistance exercises with free weights and resistance bands will allow 'site specific' strengthening. Recreational activities need to be carefully planned. For instance, golfing, tennis, and bowling may all cause excess twisting and bending (flexion) resulting in spinal pressure. Consultation with a physical therapist may give insight into proper body mechanics.

Medical treatments for the prevention and treatment of osteoporosis are numerous. In order to be approved for the treatment of osteoporosis, a medication must prove effective in reducing fracture risk. Estrogen, selective estrogen receptor modulators (SERM's), and bisphosphonates are approved for the prevention and treatment of osteoporosis in the United States. Calcitonin is a medication only approved for the treatment of osteoporosis.

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Important considerations when preventing or treating osteoporosis is adequate calcium and vitamin D intake. Although calcium intake alone will not protect a menopausal women from osteoporosis, adequate intake will ensure that calcium deficiency is not contributing to a weakening skeletal system. The National Institutes of Health Consensus panel recommends 1000 milligrams of calcium for adult women until menopause.

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After menopause, the recommended range is 1000 to 1500 milligrams of calcium per day. If taking hormone replacement therapy or other preventative medications, the usual recommended dose is 1000 to 1200 milligrams per day. If not taking preventative medications in menopause, the recommendation is 1500 milligrams per day.

Calcium products are numerous and often of vary in quality and dose. The amount of calcium absorbed and utilized by the bone depends on a number of factors, including the solubility of the product, dose, number of dosages per day, and potential interference from co-ingested foods and medications. For instance, antacids can impair the absorption of calcium. Approximately 3-5% of patient's report occasional gas cramps when taking any calcium supplement. Fortunately, taking with meals will increase absorption of the supplement while reducing cramps. When deciding on a calcium product, evaluating the amount of elemental calcium per dose is paramount. The calcium dosages listed above are based upon the elemental calcium per day. Calcium carbonate products (Os-Cal®, Caltrate®) contain 40% elemental calcium. Calcium citrate products (Citracal®) contain 21% elemental calcium. This factor correlates into the number of supplements necessary to achieve the appropriate dose per day. For instance, two tablets of Os-Cal® per day equate to 1000 milligrams of elemental calcium per day. Four to five tablets of Citracal® are required to achieve the same amount of elemental calcium. It is preferred to take calcium supplements in divided doses throughout the day to aid in maximal absorption and tolerability. Spacing the doses by several hours or taking your calcium supplement with meals is optimal. The absorption of various calcium products is often debated. Preliminary results from an upcoming study show calcium citrate and calcium carbonate products with equivalent absorption rates. The bottom line is that the best calcium supplement is one that is tolerated well by the individual, convenient to take, not cost prohibitive and manufactured from a quality source.
Vitamin D is essential for the calcium to be absorbed. Manufactured in the skin after exposure to ultraviolet rays from sunlight, vitamin D promotes absorption of calcium into the body from the gastrointestinal system. Recommended dosages for vitamin D vary depending on age and exposure to sunlight. Current guidelines suggest 400 international units (IU) per day for adults and 600 to 800 IU per day for people over age 61. Numerous calcium products contain vitamin D in appropriate amounts.

A new calcium supplement, Os-Cal Ultra®, combines an easy-to-absorb form of calcium carbonate with key nutrients critical for maintaining healthy bones and helping to prevent osteoporosis, including Vitamin D, Magnesium, zinc, copper, manganese, boron, vitamin C, and Vitamin E.

Dietary components
Knowledge of calcium containing foods is one way to increase the amount of calcium in you diet. Dairy products (including cheese), and broccoli are common calcium containing foods. One 8-ounce glass of milk contains approximately 300 milligrams of calcium, while a cup of yogurt contains 200 - 400 milligrams. Fortified foods, including orange juice and nutritional bars also contain extra calcium. Unfortunately, the number of calories ingested to obtain an adequate calcium intake from dietary products is often deemed excessive. Therefore, supplementation with a calcium product is often utilized.

References:
(1) Osteoporosis ACOG educational bulletin, #246, April 1998, pg. 664
(2) Hernadez-Avila M, Colditz GA, Stampfer MJ, Rosner B, Speizer FE, Willett WC. Caffeine, moderate alcohol intake, and risk of fractures of the hip and forearm in middle-aged women. Am J Clin Nutr 1991;54:157-163.
(3) Dalsky GP, Stocke KS, Ehsani AA, Slatopolsky E, Lee WC, Birge SJ jr. Weight-bearing exercise training and lumbar bone mineral content in postmenopausal women. Ann Intern Med 1988;108:824-828.
(4) Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis; Flexion versus extension exercises. Arch Phys Med Rehabil 1984;65:593-6

The information provided by MenopauseRx, Inc. is not intended to replace the medical advice of your doctor or health-care provider. Please consult your health-care provider for advice about a specific medical condition.