Osteoporosis

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Bone is made of collagen fibres (tough, elastic fibres) and minerals (gritty, hard material). Bone is a living tissue and contains cells that make and mould bone. After about the age of 45, you lose a certain amount of bone material. The bones become less dense and less strong. The amount of bone loss can vary. If you have a lot of bone loss, then you have osteoporosis. If you have osteoporosis you have bones that will break more easily than normal, especially if you have an injury such as a fall.

Women lose bone material more rapidly than men especially after the menopause when the level of oestrogen falls. Oestrogen is a female hormone and helps to protect against bone loss. By the age of 70 some women have lost 30% of their bone material. In the UK, about half of women and about 1 in 5 men over the age of 50 will fracture a bone, many as a result of osteoporosis.

All men and women have some risk of developing osteoporosis as they become older, particularly over the age of 60. Women are more at risk than men. The following situations also increase the risk of developing bone loss and osteoporosis. If you:

• are a woman who had your menopause before the age of 45.
• have already had a bone fracture after a minor fall or bump.
• have a strong family history of osteoporosis.
• have a body mass index (BMI) of 19 or less. (That is, you are very underweight.) For example, if you have anorexia nervosa. In this situation the level of oestrogen is often low for long periods of time and, combined with a poor diet, can affect the bones.
• are a woman and your periods stop for a year or more before the time of your menopause. This can happen for various reasons.
• have taken, or are taking, a steroid medicine (such as prednisolone) for three months or more. A side-effect of steroids is to cause bone loss.
• smoke
• lack calcium and/or vitamin D (due to a poor diet and/or little exposure to sunlight.)
• have never taken regular exercise, or have led a sedentary lifestyle (particularly during your teenage years).
• have, or had, certain medical conditions that can affect the bones. For example, an overactive thyroid, Cushing's disease, and any condition that causes poor mobility.

How is osteoporosis diagnosed?

Your GP or other health professional may ask you questions to see how many of the risk factors listed above apply to you. If you may be at risk you may then be referred for a DEXA scan. DEXA stands for Dual Energy X-ray Absorptiometry. It is a scan that uses special X-ray machines that can check the bone density and confirm osteoporosis. However, osteoporosis is often first diagnosed when you break a bone after a minor bump or fall.

Osteoporosis usually develops slowly over several years without any symptoms. However, after a certain amount of bone loss, the following may occur:

A bone fracture after a minor injury such as a fall
If you have osteoporosis, the force of a simple fall to the ground is often enough to fracture a bone. (A simple fall to the ground from standing does not usually cause a fracture if you do not have osteoporosis.) The fractures are most commonly of the hip, wrist, and vertebrae (the bones that make up the spine). A fractured bone in an older person can be serious. For example, about half the people who have a hip fracture are unable to live independently afterwards.

It is estimated that about 1 in 3 people over the age of 65 have a fall each year, increasing to 1 in 2 people aged 80 years and older. Over 60,000 people have a hip fracture each year in the UK, and about 19 in 20 of these are the result of a fall in those who have osteoporosis.

Loss of height, persistent back pain and a stooping (bent forward) posture
These symptoms occur if you develop one or more fractured vertebrae which become 'squashed' with the weight of the body. A vertebra with osteoporosis may fracture even without a fall or significant force on it. Over 120,000 vertebral fractures occur each year in the UK and only about 1 in 4 of these are caused by a fall.

The following helps to prevent, or slow down, bone loss. This advice is for everyone. But, it is particularly important if you have an increased risk of developing osteoporosis, or already have it.

Exercise
Regular weight-bearing exercise throughout life is best, but it is never too late to start. This means exercise such as brisk walking, aerobics, dancing, running, etc. For older people, a regular walk is a good start. However, the more vigorous the exercise, the better. For most benefit you should exercise regularly - at least 30 minutes of moderate exercise or physical activity at least 4-5 times per week. A separate leaflet called 'Exercise and Health' gives more details.

Exercise helps because the pulling and tugging on the bones by the muscles helps to stimulate bone-making cells and strengthens the bones. It also gives strength to the supporting muscles around bones. This helps to increase tone, balance, etc, which may help to prevent you from falling. Note: excessive exercise such as marathon running may not be so good.

Research studies have shown that moderate levels of activity, including walking, decreases the risk of having a hip fracture in older women.

Food and Diet
Calcium and vitamin D are important for bone health. The recommended daily intake for calcium in adults is 700 mg, but more may be required for people with osteoporosis. Everyone over 65 years should aim to take 400 IU of vitamin D daily. Briefly:

Calcium - you can get 700-1000 mg of calcium most easily by:

• drinking a pint of milk a day, plus
• eating 60 g (2 oz) hard cheese such as Cheddar or Edam, or one pot of yoghurt (125 g), or 60 g of sardines.

Vitamin D - there are only a few foods that are a good source of vitamin D. Approximately 115 g (4 oz) of cooked salmon or cooked mackerel provide 400 IU of vitamin D. The same amount of vitamin D can also be obtained from 170 g (6 oz) of tuna fish or 80 g (3 oz) of sardines (both canned in oil). Vitamin D is also made by your body after exposure to the sun. (The ultraviolet rays in sunshine triggers your skin to make vitamin D.) For most people over 65, an adequate amount of vitamin D can only be achieved by taking vitamin D supplements. A dietary supplement of vitamin D is commonly recommended for people over the age of 65 and for others who may lack vitamin D such as people who have a poor diet and people whose exposure to sunlight is limited. For example, women whose whole body is always covered by clothing.

If you are unsure about whether you should have calcium or vitamin D supplements, ask your practice nurse or GP.

Smoking and drinking
Chemicals from tobacco in the bloodstream can affect the bones and make bone loss worse. If you smoke, you should make every effort to stop. Also, cut down on alcohol if you drink heavily.

Hormone replacement therapy (HRT)
HRT contains oestrogen. A few years ago HRT was widely used to prevent osteoporosis. However, the recent findings on the potential long-term health risks of HRT have meant that it is not now commonly used for this purpose (except in women who have had an early menopause).

What are the treatments for osteoporosis?

Medication and/or lifestyle advice may be advised if you develop osteoporosis.

Medication to prevent and treat bone loss
Various drugs are available. Once medication for osteoporosis is started, it is likely that you will need it for the rest of your life.

• The bisphosphonates are a group of drugs that include alendronate, risedronate, etidronate, and ibandronate. These are the most commonly used drugs to treat osteoporosis. They work on the bone-making cells. They can help to restore some lost bone, and help to prevent further bone loss. Research studies have shown that the risk of bone fracture is reduced by taking one of these drugs.
• Strontium ranelate is an alternative if a biphosphonate is not suitable.
• Calcitonin, raloxifene and Parathyroid hormone are other alternative drugs that are used if a biphosphonate or strontium ranelate are not suitable. They too have research evidence to show that they reduce the risk of bone fractures.

Calcium and vitamin D tablets
These dietary supplements are commonly prescribed in addition to one of the above drugs. The body needs plenty of calcium and vitamin D to make bone.

Lifestyle
Medication will not restore all lost bone. Therefore, in addition to medication, lifestyle measures are also important (exercise, not smoking, etc, as described above).

Preventing falls
You can take measures to help prevent you from falling. This can reduce your risk of breaking a bone.

• Check your home for hazards such as uneven rugs, trailing wires, slippery floors, etc.
• Regular weight bearing exercise may help to prevent falls (as described above).
• Are your vision and hearing as good as possible? Do they need checking? Do you need glasses or a hearing aid?
• Beware of going out in icy weather.
• Do you take any drugs that can make you drowsy? Can they be changed?

If you have had a fall, or have difficulty walking, you may be advised to have a formal 'falls risk assessment'. This involves various things such as a physical examination, checking your vision, hearing, and ability to walk, reviewing your medication, and reviewing your home circumstances. Following this, where appropriate, some people are offered things such as a muscle strengthening and balance programme, or recommendations on how to reduce potential hazards in the home.

Further information

National Osteoporosis Society
Camerton, Bath, BA2 0PJ
Helpline: 0845 4500230
Web: www.nos.org.uk

© EMIS and PIP 2006   Updated: May 2006   PRODIGY Validated

The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest. Find out more about updating.

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