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Osteoporosis
Copyright 2007 The New York Times Company
http://health.nytimes.com/health/guides/disease/osteoporosis/overview.html#Treatment
Osteoporosis
Osteoporosis is a condition characterized by progressive loss of bone density, thinning of bone tissue and increased vulnerability to fractures. Osteoporosis may result from disease, dietary or hormonal deficiency or advanced age. Regular exercise and vitamin and mineral supplements can reduce and even reverse loss of bone density.
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Hip fractures occur as a result of major or minor trauma. In elderly patients with bones weakened by osteoporosis, relatively little trauma, even walking, may result in a hip fracture.
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Vitamin D Source
Like most vitamins, vitamin D may be obtained in the recommended amount with a well-balanced diet, including some enriched or fortified foods. In addition, the body manufactures vitamin D when exposed to sunshine, and it is recommended people get 10 to 15 minutes of sunshine 3 times a week.
Calcium requires adequate vitamin D in order to be absorbed by the body. In the United States , many food sources of calcium such as milk are fortified with vitamin D.
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Calcium Source
Getting enough calcium to keep bones from thinning throughout a person's life may be made more difficult if that person has lactose intolerance or another reason, such as a tendency toward kidney stones, for avoiding calcium-rich food sources. Calcium deficiency also effects the heart and circulatory system, as well as the secretion of essential hormones. There are many ways to supplement calcium, including a growing number of fortified foods.
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Bone-building Exercise
Exercise plays an important role in maintaining bone calcium and strength as people age. Studies show that exercises requiring muscles to pull on bones (resistance exercise) cause the bones to retain and possibly gain calcium (density).
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Changes in Spine With Age
The spine weakens with age, becoming more curved and more fragile.
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Osteoporosis is the thinning of bone tissue and loss of bone density over time.
Osteoporosis is the most common type of bone disease. An estimated 10 million Americans have osteoporosis, as well as another 18 million who have low bone mass, or osteopenia, which may eventually lead to osteoporosis if not treated.
Researchers estimate that about 1 out of 5 American women over the age of 50 have osteoporosis. About half of all women over the age of 50 will have a fracture of the hip, wrist, or vertebra (bones of the spine).
Osteoporosis occurs when the body fails to form enough new bone, when too much old bone is reabsorbed by the body, or both.
Calcium and phosphate are two minerals that are essential for normal bone formation. Throughout youth, your body uses these minerals to produce bones. If you do not get enough calcium, or if your body does not absorb enough calcium from the diet, bone production and bone tissues may suffer.
As you age, calcium and phosphate may be reabsorbed back into the body from the bones, which makes the bone tissue weaker. This can result in brittle, fragile bones that are more prone to fractures, even without injury.
Usually, the loss occurs gradually over years. Many times, a person will have a fracture before becoming aware that the disease is present. By the time this occurs, the disease is in its advanced stages and damage is severe.
The leading causes of osteoporosis are a drop in estrogen in women at the time of menopause and a drop in testosterone in men. Women, especially those over age 50, get osteoporosis more often than men.
Other causes include:
· Being confined to a bed
· Excess corticosteroid levels due to ong oing use of medicines for asthma, certain forms of arthritis or skin diseases, and COPD.
· Rheumatoid arthritis and other inflammatory conditions
White women, especially those with a family history of osteoporosis, have a greater-than-average risk of developing osteoporosis. Other risk factors include:
· Absence of menstrual periods (amenorrhea)
· Drinking large amount of alcohol
· Early menopause
· Family history of osteoporosis
· Low body weight
· Smoking
· Too little calcium in the diet
· Use of certain medications, including steroids and antiseizure drugs
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There are no symptoms in the early stages of the disease.
Symptoms occurring late in the disease include:
· Fractures with little or no trauma
· Loss of height over time
· Low back pain due to fractures of the spinal bones
· Neck pain due to fractures of the spinal bones
· Stooped posture
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Bone mineral density testing (specifically a densitometry or DEXA scan) measures how much bone you have. This test has become the gold standard for osteoporosis eval uation. For specific information on such testing, see bone density test.
A spine CT can show loss of bone mineral density. Quantitative computed tomography (QCT) can eval uate bone density. However, it is not as available and is more expensive than a DEXA scan.
In severe cases, a spine or hip x-ray may show fracture or collapse of the spinal bones. However, simple x-rays of bones are not very accurate in predicting whether someone is likely to have osteoporosis.
You may need other blood and urine tests if your osteoporosis is thought to be due to a medical condition, rather than simply the usual bone loss seen with older age.
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Treatment
The goals of osteoporosis treatment are to:
· Control pain from the disease
· Slow down or stop bone loss
· Prevent bone fractures with medicines that strengthen bone
· Minimize the risk of falls that might cause fractures
There are several different treatments for osteoporosis, including a variety of medications.
BISPHOSPHONATES
Bisphosphonates are a type of drug used for both the prevention and treatment of osteoporosis in postmenopausal women. Several bisphosphonates are approved for the treatment of osteoporosis in the United States , including alendronate (Fosamax), ibandronate (Boniva), and risedronate (Actonel). Most are taken by mouth, usually onc e a week or onc e a month. Bisphosphonates given through a vein (intravenously) are taken less often.
CALCITONIN
Calcitonin is a medicine that slows the rate of bone loss and relieves bone pain. It comes as a nasal spray or injection. The main side effects are nasal irritation from the spray form and nausea from the injectable form.
While calcitonin slows bone loss and reduces the risk of fractures, it appears to be less effective than bisphosphonates.
HORMONE REPLACEMENT THERAPY
Estrogens are still used to prevent osteoporosis but are not approved to treat a woman who has already been diagnosed with the condition.
Sometimes, if estrogen has helped a woman, and she cannot take other options for preventing or treating osteoporosis, the doctor may recommend she continue using hormone therapy. If you are considering taking hormone therapy to prevent osteoporosis, discuss the risks with your doctor.
Over the past decade, several major studies eval uated the health benefits and the risks of hormone therapy, including the risk of developing breast cancer, heart attacks, strokes, and blood clots. Evidence from these studies raised concerns for an increased risk for stroke, heart disease, breast cancer, and blood clots, depending on several factors that include the types of hormones used
Some women may still wish to consider hormone therapy for short-term treatment of menopausal symptoms. The key is to weigh the risks associated with taking hormone therapy against a particular woman's risk of heart disease or osteoporosis without taking hormone therapy. Other factors to consider include:
· A woman's age
· The age menopause started
· The dose of hormone therapy being considered
· Prior hormone replacement therapy taken in the past
· Quality of life issues
Every woman is different. Your doctor should be aware of your entire medical history when considering hormone therapy.
PARATHYROID HORMONE
Teriparatide (Forteo) is approved in the United States for the treatment of postmenopausal women who have severe osteoporosis and are considered at high risk for fractures. The medicine is given through daily shots underneath the skin. You can give yourself the shots at home.
RALOXIFENE
Raloxifene (Evista) is used for the prevention and treatment of osteoporosis. Raloxifene is similar to the breast cancer drug tamoxifen. Raloxifene can reduce the risk of spinal fractures by almost 50%. However, it does not appear to prevent other fractures, including those in the hip. It may have protective effects against heart disease and breast cancer, though more studies are needed.
The most serious side effect of raloxifene is a very small risk of blood clots in the leg veins (deep venous thrombosis) or in the lungs (pulmonary embolus).
EXERCISE
Regular exercise can reduce the likelihood of bone fractures associated with osteoporosis. Some of the recommended exercises include:
· Weight-bearing exercises -- walking, jogging, playing tennis, dancing
· Resistance exercises -- free weights, weight machines, stretch bands
· Balance exercises -- tai chi, yoga
· Riding stationary bicycles
· Using rowing machines
· Walking
· Jogging
Avoid any exercise that presents a risk of falling.
DIET
Get at least 1,200 milligrams per day of calcium, and 800 - 1,000 international units of vitamin D3. Vitamin D helps your body absorb calcium.Your doctor may recommend a supplement to give you the calcium and vitamin D you need.
Follow a diet that provides the proper amount of calcium, vitamin D, and protein. While this will not completely stop bone loss, it will guarantee that a supply of the materials the body uses to form and maintain bones is available.
High-calcium foods include:
· Cheese
· Ice cream
· Leafy green vegetables, such as spinach and collard greens
· Low-fat milk
· Salmon
· Sardines (with the bones)
· Tofu
· Yogurt
STOP UNHEALTHY HABITS
Quit smoking, if you smoke. Also limit alcohol intake. Too much alcohol can damage your bones, as well as put you at risk for falling and breaking a bone.
PREVENT FALLS
It is critical to prevent falls. Avoid sedating medications and remove household hazards to reduce the risk of fractures. Make sure your vision is good. Other ways to prevent falling include:
· Avoiding walking alone on icy days
· Using bars in the bathtub, when needed
· Wearing well-fitting shoes
MONITORING
Your response to treatment can be monitored with a series of bone mineral density measurements taken every 1-2 years. However, such monitoring is controversial and expensive.
Women taking estrogen should have routine mammograms, pelvic exams, and Pap smears.
RELATED SURGERIES
There are no surgeries for treating osteoporosis itself. However, a procedure called vertebroplasty can be used to treat any small fractures in your spinal column due to osteoporosis. It can also help prevent weak vertebra from becoming fractured by strengthening the bones in your spinal column.
The procedure involves injecting a fast-hardening glue into the areas that are fractured or weak. A similar procedure, called kyphoplasty, uses balloons to widen the spaces that need the glue. (The balloons are removed during the procedure.)
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Outlook (Prognosis)
Some persons with osteoporosis become severely disabled as a result of weakened bones. Hip fractures leave about half of patients unable to walk independently. This is one of the major reasons people are admitted to nursing homes.
Although osteoporosis is debilitating, it does not affect life expectancy.
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Possible Complications
· Compression fractures of the spine
· Disability caused by severely weakened bones
· Hip and wrist fractures
· Loss of ability to walk due to hip fractures
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When to Contact a Medical Professional
Call your health care provider if you have symptoms of osteoporosis or if you wish to be screened for the condition.
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Prevention
Calcium is essential for building and maintaining healthy bone. Vitamin D is also needed because it helps your body absorb calcium. Following a healthy, well-balanced diet can help you get these and other important nutrients throughout life.
Other tips for prevention:
· Avoid drinking excess alcohol
· Don't smoke
· Get regular exercise
A number of medications are approved for the prevention of osteoporosis.
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The (Often Neglected) Basics for Keeping Bones Healthy
By GINA KOLATA
In surveys and focus groups, most Americans say they know what to do to protect themselves against osteoporosis, the disease of fragile bones that often occurs in the elderly: eat lots of calcium-rich foods or take a calcium supplement.
Many say they are doing just that, or plan to.
But this response worries osteoporosis researchers like Dr. Joan McGowan, chief of the musculoskeletal diseases branch at the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
Consuming calcium, she and others note, can at best make a small difference in osteoporosis risk, while other methods that can have a more substantial effect are often ignored.
Dr. McGowan is one of two scientific editors of the surgeon general's report on bone health that was released last week. The report has an ambitious goal: to educate doctors and the public so that they can put into practice what researchers know about preventing and detecting the bone disease.
The lack of this knowledge, Dr. McGowan said, often leads to bad practice.
For example, she said, doctors should routinely eval uate people over 50 who break a bone, for any reason, to see if they have osteoporosis. But such eval uations are seldom ordered.
Doctors should also make sure that older people get enough vitamin D, because deficiencies greatly increase fracture risk, Dr. McGowan said. But this, too, is rarely done.
Osteoporosis, the most common bone disease, is grimly serious, afflicting 10 million Americans over age 50 annually.
Each year, the report found, about 1.5 million Americans break bones because of osteoporosis, costing the health care system $18 billion. Often, the bone that is broken is the hip. And a hip fracture can set off a spiral leading to a nursing home and death: 20 percent of people who break a hip die within a year, the report said.
Osteoporosis can be prevented and treated with drugs that keep bones from breaking down - if people realize that they have it.
The report urges that doctors and patients pay attention to bones throughout life. Children and adolescents need a proper diet and exercise to stimulate bone growth. For adults, eating properly and staying active can maintain bone strength.
The report recommends that people over 50 who are at high risk for osteoporosis - women with a strong family history of the disease, for example - and anyone over 65 have a bone density test. Older people should also take simple measures to prevent falls, like removing small rugs from their homes.
But paying close attention to fractures is near the top of most experts' list of largely ignored medical interventions.
"When you see people over 50 who fall and break a wrist bone, you need to stop and take a look," said Dr. Richard H. Carmona, the surgeon general. "We need to take one step back and say, 'Why should that bone have broken from a simple fall?' "
That advice is not just for broken wrist bones, Dr. McGowan added.
"One of the ideas that people have is that you earned your fracture," she said. "You tripped, or you were ice skating with your granddaughter and you fell and broke your arm. Well, how many times did your granddaughter fall and not break an arm?"
Dr. McGowan said that a fracture was "really a sentinel event in an older person - any fracture."
"I don't care if you got it falling off a bike or even in a traffic accident," she continued.
Yet too often, she said, doctors do not send patients with broken bones to be eval uated to see why the bone broke in the first place.
The American Academy of Orthopaedic Surgeons agrees.
In a position statement last year, it urged members to do more than just repair fractures in older people.
"There is a terrific information gap," said Dr. Laura Tosi, an orthopedic surgeon at George Washington University and a member of the academy's board. "Orthopods know how to put metal in and get people up and going, but if you don't prevent future fractures, people will end up disabled."
It is not just orthopedists who often miss opportunities. In a paper published last year in The Journal of Clinical Endocrinology & Metabolism, Dr. Ethel Siris, director of the Toni Stabile Osteoporosis Center at New York-Presbyterian Hospital/Columbia University Medical Center in New York , and her colleagues reviewed the data and found it depressing.
"In virtually all the reports that have been published in the past few years, physicians who deal directly with the fracture event rarely take appropriate action," they wrote. "This includes radiologists who review X-rays that include the spine, orthopedic surgeons who treat acute fractures, physiatrists who oversee rehabilitation after the fracture, and primary care physicians to whom the patients return for overall care onc e the fracture has healed."
For example, in one study reviewed in the paper, of 934 women over age 60 who had routine chest X-rays, 132 had visible moderate to severe vertebral fractures. But onl y 17 of them had these fractures noted on their discharge statements.
Another underappreciated problem, osteoporosis experts say, is a lack of vitamin D, which bones need to absorb calcium and phosphorus. Vitamin D deficiencies greatly increase the risk of fractures. Yet a new national study by Dr. Michael Holick of Boston University, of about 1,500 postmenopausal women with osteoporosis, found that half had vitamin D levels below what is considered ideal.
Vitamin D is made in the skin in response to sun exposure, but many people do not get enough sunlight, Dr. Siris said, noting that there is a concern about skin cancer. "People today are sun-averse," she said. "And in the elderly, who don't go outdoors, this is a real issue."
She added that the deficiency was easily corrected by vitamin D supplements that cost as little as $3.40 for 100 pills.
Osteoporosis is a real problem, Dr. Siris said. "This is not something made up by the pharmaceutical industry."
But for people who are worried about ending their days bent over with the disease, or with a broken hip in a nursing home, Dr. Carmona has a message.
"You don't have to be a hunched over old lady or old man," he said. "If you pay attention to bone health."
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