Our bones are living tissues that are constantly being remodelled. This is managed through specific cells that maintain the balance between new bone formation and break down of old bone. Osteoblasts are the cells involved for making new bone whilst osteoclasts are responsible for breaking down old bone. In certain circumstances, old bone is broken down at a faster rate than new bone is formed, leading to an imbalance in bone architecture (1).
This can result in a condition known as osteoporosis which is characterised by micro-architectural deterioration of bone tissue and decreased bone density. As a result, people with osteoporosis are often predisposed to increased bone fragility and susceptibility to fracture (2).
Risk Factors for the development of osteoporosis
Early menopause and Post-menopausal women
Research has established that post-menopausal women above 50 as well as those who subdue early menopause are the most frequent sub-type of people at risk for the development of osteoporosis. This is a result of hormonal changes that occur in peri and post-menopausal women, where there is a decrease in the hormone oestrogen used to help maintain bone density (3).
Age
Bone density is suggested to peak around 25-30 years old. However, as we age, changes within our bone metabolism occur whereby our bone mass slowly starts to decrease. As a result, osteoporosis is most commonly seen between the ages of 60-80 (3).
Gender and Genetics
Research has established that women are four times more likely to develop osteoporosis than men. In addition to this, Asian and Caucasian females as well as people with a family history of osteoporosis are at higher risk than African and Afro-Caribbeans or people with no family history of the disease. (4)
Body Mass Index
Petite, thin people or individuals with a history of eating disorders are more likely to develop osteoporosis.
Lifestyle Factors
Lifestyle and dietary factors including smoking, alcoholism and poor diet have been linked to osteoporosis.
History of Cortico-steroid use
People with various inflammatory and auto-immune diseases are often medicated with cortico-steroids which are used to target inflammation. A common adverse effect of long-term steroid use is a decrease in the metabolism of calcium, vitamin D and bone formation which can lead to more fragile bones (4).
Hormonal and Malabsorption Diseases
Various hormonal imbalances and malabsorption conditions including thyroid disorders, brittle bone disease, gastrointestinal malabsorption and vitamin D deficiency are known risk factors for osteoporosis (4).
What are the symptoms of osteoporosis?
Often early stages of osteoporosis are silent and frequently results in no symptoms. As a result of this, many people with underlying osteoporosis remain undiagnosed. This can lead to low impact bone fractures which can result in significant health disabilities. Areas of fracture can occur anywhere from the wrist, arm and leg to spine, hip and pelvic (5). Depending on severity, osteoporotic related fractures have poor prognosis and at times can lead to mortality. However, some early symptoms may include:
- non-specific joint, bone and muscle pain
- height loss or stooped posture
- decreased strength and low overall fitness
How is osteoporosis diagnosed?
The gold standard for diagnosis is through Dual X-Ray Absorptiometry (DXA) which measures bone mineral density (BMD) levels on various parts of the body (6).
What do the test results mean?
The world health organisation (WHO) has defined several threshold measurements for osteoporosis. The reference values are derived from BMD measurements in a population of young adults, called a “T-score”. Osteoporosis is diagnosed when a persons’ BMD is equal to or more than 2.5 standard deviations below the reference value (6).
Osteopenia, which is the stage before osteoporosis, is when the measurement is between 1 and 2.5 standard deviations below the young adult reference measurement.
Prevention and early diagnosis
Because osteoporosis is frequently symptomless until a fracture occurs, early diagnosis and prevention are highly recommended to help avoid any disease progression. If you are aware that you have several risk factors for the disease and are between 55-65, consult your GP and request to get screened.
Patients who do not meet diagnostic criteria with a T-score greater than -2.5 but who are at risk are advised on strategies to reduce their risk (7). These factors include a presence of osteopenia, chronic use of corticosteroids, or family history of osteoporosis.
What can help with prevention
- regular weight-bearing and muscle strengthening exercise to maintain and improve bone strength
- dietary changes with increased protein intake
- calcium and vitamin D supplements
- reduce smoking
- reduce alcohol intake
Treatment
Once a diagnosis of osteoporosis has been made and the underlying causes have been identified, it is advised that the main aim of treatment is to prevent any further fractures. Therefore, prompt evaluation and treatment are implemented to prevent any fracture-related morbidity. Treatment currently including both pharmaceutical and non-pharmaceutical management.
Pharmaceutical Management
Dosages and drug type are primarily dependant on the severity of the disease and what levels your bone density are (8). Common pharmaceutical interventions that aim to maintain bone density and prevent any further deterioration include:
- bisphosphates
- calcitonin
- SERMS
- Parathyroid hormone
- Calcium and vitamin D supplements
Non- Pharmaceutical management
- Weight bearing and resistance exercise
- Cessation of tobacco use
- Decrease alcohol intake if excessive
- Physical therapy for balance/strength training
- Fall risk reduction through home and environmental modifications
Patients undergoing treatment for osteoporosis should be evaluated regularly to ensure appropriate supplement and pharmaceutical intake as well adherence to lifestyle changes. The National Osteoporosis Foundation practise guidelines recommend obtaining bone density tests every 2 years as a means of guiding medication management (8).
Reference list
- Matcuk, G. R., Mahanty, S. R., Skalski, M. R., Patel, D. B., White, E. A., & Gottsegen, C. J. (2016). Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options. Emergency radiology, 23(4), 365-375.
- Cosman, F., De Beur, S. J., LeBoff, M. S., Lewiecki, E. M., Tanner, B., Randall, S., & Lindsay, R. (2014). Clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis international, 25(10), 2359-2381.
- Hillier, T. A., Cauley, J. A., Rizzo, J. H., Pedula, K. L., Ensrud, K. E., Bauer, D. C., … & LeBlanc, E. S. (2011). WHO absolute fracture risk models (FRAX): do clinical risk factors improve fracture prediction in older women without osteoporosis?. Journal of Bone and Mineral Research, 26(8), 1774-1782.
- Liu, W., Yang, L. H., Kong, X. C., An, L. K., & Wang, R. (2015). Meta-analysis of osteoporosis: fracture risks, medication and treatment.
- Cosman, F., De Beur, S. J., LeBoff, M. S., Lewiecki, E. M., Tanner, B., Randall, S., & Lindsay, R. (2014). Clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis international, 25(10), 2359-2381.
- Tella, S. H., & Gallagher, J. C. (2014). Prevention and treatment of postmenopausal osteoporosis. The Journal of steroid biochemistry and molecular biology, 142, 155-170.
- Golob, A. L., & Laya, M. B. (2015). Osteoporosis: screening, prevention, and management. Medical Clinics, 99(3), 587-606.
- Kling, J. M., Clarke, B. L., & Sandhu, N. P. (2014). Osteoporosis prevention, screening, and treatment: a review. Journal of women’s health, 23(7), 563-572.