Doctor Feeling Female Patient's Forehead

When most people think of osteoporosis, they think of a grandmother who fell and broke her hip, or the little, old person in the Life Alert commercials yelling, “Help! I’ve fallen and I can’t get up!” Sadly, most Americans are misinformed about skeletal fragility and osteoporosis – rates of disease in both men and women, consequences, and complications, as well as screening and treatment options.

Most people think of osteopenia and osteoporosis as the inevitable decrease in bone density that comes along with aging, or as the “brittle bone disease.” This is partially correct. Osteoporosis is a skeletal disorder that causes decreased bone strength. This results in skeletal fragility, or increased fracture risk. Osteoporosis is the most common bone disease in humans and while we all will have an age-related decline in bone density, the severe decrease seen in osteoporosis is not considered a normal part of aging.

Osteoporosis is a silent disease that doesn’t cause symptoms until a patient sustains a low-velocity or atraumatic fracture. These are fractures that occur with very little injury or force, or without an actual injury. Skeletal fragility fractures most commonly occur in the vertebrae, hip, and forearm.

In the United States, approximately 43 million people have osteopenia (pre-osteoporosis) and 10 million people have osteoporosis. Annually in the US, osteoporosis is associated with 2 million fractures, nearly 500,000 hospital admissions, 2.5 million doctor’s office visits, and 180,000 nursing home admissions.

Many recent studies are showing startling results: patients are being under-screened and under-treated for osteopenia and osteoporosis. As many as 80% of patients with osteoporosis are either under-treated or are not treated at all. Likewise, in patients who have sustained a fragility fracture, only 10% receive appropriate follow-up medical care and screening for their osteoporosis.

So why does this matter?

Fragility fractures are rated as the leading cause of disability and loss of independence in older adults. For patients who sustain an osteoporotic hip fracture, the prognosis can be bleak. Only 40% of women who sustain a hip fracture will regain pre-fracture functional status, and as many as 36% (depending on risk and age) will not survive one year after the fracture. Compared to women, twice as many men with hip fractures will die within the first six months after the fracture.

Due to societal misconceptions and miseducation about osteoporosis in men, they are at especially high risk for poor screening and treatment rates. One in five men, aged 50 years and over, will sustain a fragility fracture. That rate increases significantly as men age past 75 years old. Men account for 25% of all fragility fractures and have a higher lifetime risk of developing osteoporosis than prostate cancer.

Thin, post-menopausal Caucasian females have the highest risk for developing skeletal fragility. However, women who don’t fit that profile aren’t off the hook! 50% of all post-menopausal women will sustain a fragility fracture. Compared to breast cancer, of which women have a 1:9 lifetime risk, osteoporosis carries a 1:6 lifetime risk. In women age 45 years and older, osteoporosis accounts for more days in the hospital than diabetes, heart attacks, and breast cancer.

Normal and Osteoporosis Example

In addition, there are other common risk factors for skeletal fragility. The number one risk for fragility fractures is the first fracture – so if the first fracture can be prevented, we can improve and save lives!

Other common risk factors include advanced age, family history, Caucasian or Asian background, early menopause, low estrogen in women, and low testosterone in men, chronic use of oral steroids (this does not include inhalers, topical creams, and joint injections), chronic use of PPI medications for acid reflux, chronic use of seizure medications, and variety of chronic medical conditions, such as rheumatoid arthritis, chronic kidney disease, asthma and COPD, malabsorptive GI diseases like IBS or Crohn’s, and endocrine disorders like thyroid disease and diabetes.

I recommend that my patients see their primary care providers at least once a year for a full set of annual fasting labs to make sure there are no undiagnosed, untreated medical conditions that can increase the risk for skeletal fragility.

Screening

While there is a number of ways medical providers can assess skeletal fragility, the “gold standard” in screening is the DEXA scan. This is a quick, low-cost, non-invasive, x-ray test. Results are reported in T-scores.

  • I generally recommend a DEXA scan for at least the following: all post-menopausal women, all men aged 70 and older, men age 50 and older or who have low testosterone, and any patient aged 50 and older with risks mentioned above.
  • Depending on patient risk and history, I recommend re-screening about every two years.
  • As a rule: screen early and re-screen often!

Diagnosis

Most frequently, osteopenia and osteoporosis are diagnosed based off DEXA scan T-scores. T-scores of 0 to -1 is normal for age. T-scores of -1 to -2.5 are considered osteopenia. T-scores of -2.5 or greater (worse) are considered osteoporosis. It is very important to remember that arthritis in the back and hips can cause a false-positive elevation in T-scores, as arthritis can make brittle bones appear denser on a DEXA than they actually are!

  • If a patient has a normal T-score or T-scores consistent with osteopenia, but sustains a fragility fracture, they by default now have osteoporosis.
  • The majority of fragility hip fractures in the US are in patients with T-scores in the osteopenia range!

Treatment

There are a wide variety of treatments for osteoporosis. Treatment will depend on T-scores, fracture history, and individual patient medical history. I generally classify treatments into one of three groups: bone-maintainers (bisphosphonates, like Fosamax, Boniva, Prolia, and Reclast), bone-builders (osteoanabolic, like Forteo or Tymlos), and the other guys (for example, Evista is used in patients to prevent osteoporosis and breast cancer so it can be used in certain populations).

Certain osteoporosis medications need to be temporarily stopped after a certain number of years. For example, the bisphosphonates (such as Fosamax) needs to be cycled off after 3 to 6 years of use to prevent the increased risk of fractures.

Prevention, Exercise, and Nutrition

Patients frequently ask me these two questions 1) what can do I do prevent osteoporosis, and 2) are there natural treatments?

Unfortunately, there are large genetic and medical components that contribute to the development of skeletal fragility. So, on some level, you are stuck with the genes your parents passed on to you. BUT, there are some lifestyle modifications that will decrease the risk of osteoporosis:

  • Most importantly: IF YOU SMOKE, STOP! Heavy alcohol use and a sedentary lifestyle are also big risk factors for developing skeletal fragility.
  • Our bones like weight on them and like muscles pulling on them, so frequent, weight-bearing exercise and light weight lifting is great for maintaining bone density! The additional benefit is that stronger muscles burn more calories at rest, so this is a good strategy to maintain a healthy body mass and prevent other chronic illnesses.
  • Patients frequently tell me, “But I’m being really careful that I don’t trip and fall.” While falls can absolutely result in fractures in patients with skeletal fragility, I have had numerous patients tell me, “I felt my hip break, and then I fell.” My advice: reduce fall hazards in the home, and take precautions when you are out (I recommend yak-tracks and micro-spikes for winter hiking, use of supportive footwear, and avoiding icy, slippery surfaces).
  • While there are no “natural,” over-the-counter supplements that will reverse or prevent osteoporosis, there are some vitamin/ dietary recommendations I make. It is important that you discuss any intended changes to your diet and exercise regimen with your primary care provider before starting them.
  • 1200mg of elemental calcium per day.
  • At least 2000IU of vitamin D per day. In the vast majority of my patients, this is not enough and we end up using a high-dose, prescription-strength vitamin D supplement. Colorado has an exceptionally high rate of vitamin D deficiency – so no, getting a lot of unprotected sun exposure is not only bad for your skin but not enough to prevent vitamin D deficiency.
  • I recommend a plant-based diet with healthy fats and lean proteins. This is not only good for your bones but will decrease body-wide inflammation (which is associated with many chronic diseases). Examples include cold water fish and brightly colored fresh fruits, vegetables, greens, and legumes (beans). While cooking fruits and vegetables can cause them to lose their vitamin and mineral content, naturally thawing them is safe.
  • Dairy products do contain calcium, but they also have a lot of fat. “Skim” or fat-free dairy products contain extra sugar to make up for less fat. So, as a rule, I don’t recommend going crazy with the dairy products to promote skeletal health.
  • Avoid SASS: sugars (including refined carbohydrates, like bread, rice, and pasta), alcohol, salts (processed snacks- like chips), and saturated fats (processed, fried foods).
  • Avoid soda pop

So, what’s next?

If you are a patient, I recommend making an appointment with your primary care provider to discuss your risk of skeletal fragility, screening, and things you can do to prevent fractures.

If you are a medical provider, I recommend frequent screening and re-screening of your patients, treating causes of secondary osteoporosis; and most importantly, not waiting until patients sustain fractures to start treatment.

About the author

Shannon M. Constantinides
Shannon M. Constantinides
Ph.D. Student at UCHealth Bone Health Clinic (719) 599-0444

Shannon M. Constantinides is a Ph.D. student at Florida Atlantic University in Boca Raton, Florida. Her interests include applied biostatistics and population health. She is a board-certified family nurse practitioner and currently runs the UCHealth Bone Health and Skeletal Fragility Clinic at UCHealth Primary Care at Academy.

UCHealth Bone Health Clinic
UCHealth Primary Care at Academy
5265 N. Academy Blvd, Suite #1800
Colorado Springs, CO, 80918