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A HARVARD HA RVARD MEDI ME DICAL CAL SCH SCHOO OOL L SPECIAL HE AL ALTH TH REPORT
Osteoporosis A guide guide to to preven preventio tion n and and treatm treatment ent
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OSTEOPOROSIS SPECIAL HEALTH REPORT
Medical Editor David M. Slovik, MD Endocrinologist, Massachusetts General Hospital Chief, Division of Endocrinology, Newton-Wellesleyy Hospital Newton-Wellesle Associate Professor of Medicine, Harvard Medical School
Executive Editor Anne Unde rwo od Writers Stephanie Watson, Daniel Pendick Copy Editor Robin Netherton Creative Director Judi Crouse Production /Design Manager Lori Wendin Illustrators Jesse Tarantino, Tarantino, Matt Holt Published by Harvard Medical School Gregory D. Curfman, MD, Editor in Chief Urmila R. Parlikar, Se Senior nior Content Editor In association with
Belvoir Media Group, LLC, 535 Connecticut Avenue, Norwalk, CT 06854-1713. Robert Englander, Chairman and CEO; Timothy H. Cole, Executive Vice President, Editorial Director; Philip L. Penny, Chief Operating Officer; Greg King, Executive Vice President, Marketing Director; Ron Goldberg, Chief Financial Officer; Tom Canfield, Vice President, Circulation. Copyright © 2016 by Harvard University. Permission is required to reproduce, in any manner, in whole, or in part, the material contained herein. Submit reprint requests to:
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Contents The basics of bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Two types of bone tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Bone remodeling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 The life cycle of bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
What causes osteoporosis? . . . . . . . . . . . . . . . . . . . . . . . . . .6 Primar y o os steoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Secondar y os osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Know your risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Risk factors you can’t control . . . . . . . . . . . . . . . . . . . . . . . . . . 1 10 0 Risk factors you can control . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 10 0
The consequences of osteoporosis . . . . . . . . . . . . . . . . . . 13 Hip fractures . . . . . . . . . . . . . . . . . . . . . Spinal fractures . . . . . . . . . . . . . . . . . . . Wrist fractures . . . . . . . . . . . . . . . . . . . . Other consequences. . . . . . . . . . . . . . . .
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Detecting osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 DEXA scans for bone density . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 16 6 Ver tebral fracture assessment . . . . . . . . . . . . . . . . . . . . . . . . . 1 17 7 Lab tests for bone turnover . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 18 8
Developing a plan of action. . . . . . . . . . . . . . . . . . . . . . . . 19 If you you ha have ve oste osteop open enia ia (T-s (T-sco core re bet betwe ween en –1 –1 an and d –2 –2.5 .5)) . . . . . . . .19 If you you ha have ve oste osteop opor oros osis is (T-s (T-sco core re –2 –2.5 .5 an and d be belo low) w) . . . . . . . . . . .19
Protecting your bones: Nutrition . . . . . . . . . . . . . . . . . . . . 21 Calcium and vitamin D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 21 Vitamin K. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Potential dietar y dangers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 28
Protecting your bones: Exercise . . . . . . . . . . . . . . . . . . . . 29 How we weight-bearing e exxercise be benefits b bo ones . . . . . . . . . . . . . . . . 29 Classic strength training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 30 0 Preventing falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
SPECIAL SECTION Strength Stren gth trainin training g and balanc balance e exercises exercises for for bone bone health health . . 34
Protecting your bones: Medication . . . . . . . . . . . . . . . . . . 39 Bisphosphonates . . . . . SERMs . . . . . . . . . . . . Monoclonal a an ntibodies . Hormones . . . . . . . . . .
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Coping with fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Living with a hip fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 51 Suppor t groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
ISBN 978-1-61401-124-8 The g oal of mater ials p rovi ded b y Har vard Healt h Pub lica tions is to interpret medical information for the general reader. This r epor t is no t inte nded as a su bst itut e for p ers onal me dical advice, which should be obtained directly from a physician.
Glossar y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Cover Image: © Wavebreakmedia Ltd | Thinkstock
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Dear Reader, “Hard as bone”—that’s an expression we’ve all heard. But what does it really mean? Healthy bones are indeed hard. Your skeletal system does yeoman’s work in supporting your body and acilitating your movements. But when you have osteoporosis (literally “porous bone”), you can no longer count on your skeleton to be sturdy enough to withstand even routine stress. A twist, a bend, an unexpected jolt—all can snap a dangerously weak bone. Sadly, many people have no inkling that they have been losing bone b one mass or years years until a painul racture o the wrist, spine, or hip brings the problem into sharp ocus. More than 10 million Americans currently live with osteoporosis, and another 43 million show early signs o bone loss. And those t hose numbers are expected to grow as baby boomers bo omers age. According to the National Osteoporos Osteoporosis is Foundation, an estimated 64 million Americans over age 50 are expected to have low bone density or osteoporosis by 2020. Tat number will jump to more than 71 million by 2030, resulting in more bone ractures. For the individual, the consequences o an osteoporosis-rela osteoporosis-related ted racture can be b e devastating. Many older adults never regain the good health and quality o lie they enjoyed beore suffering a broken bone. Physical comp complications lications ranging rom ongoing pain and stooped posture to breathing and digestive problems are common. Hip ractures can significantly impair a person’s mobility,, making it impossible to drive, co mobility cook, ok, or even walk across a room without assistance. But you don’t have to wait until the damage is done to fight this disease. You can start making liestyle changes at any age that will promote good bone health and prevent or delay severe bone loss. Ways Ways o doing that are detailed in tthis his report. And i you already have the disease, there have never been more options or treating it. Doctors have sophisticated tools to detect bone thinning in the earliest stages and identiy those who should begin treatment and when. For those in greatest danger o an osteoporosis-related racture, racture, a number o highly effective medications to curb bone loss are already available, and more are on the way. By learning about osteoporosis, you’re you’re taking a step toward better bone health. Tis report can help you become aware o your risk and serve as a guide or making tthe he liestyle changes that have been proved to reap long-term bone benefits. Regardless o your age, it’s never too late— or too early—to begin boning up on bone health. Sincerely,
David M. Slovik, M.D. Medical Editor Editor
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The basics of bone
Y
our bones are surprisingly strong. Ounce or ounce, they bear as much weight as reinorced
As you age, that process o lux inevitably includes losing some o your youthul bone density, as
concrete. But unlike concrete, bone isn’t inert. It is a living tissue that can grow stronger in response to stresses and heal itsel i injured. Bones serve many roles in the body. Tey support your weight. Tey join orces with muscles, ligaments, and tendons to allow complex, highly articulated movements. Less obviously, they also serve as a repository o minerals that are used by the body. Like a savings bank, they allow both withdrawals and deposits o their mineral assets—a process that requires breaking down and rebuilding part o the bone matrix in order to release or absorb the minerals. Tus, even though bones seem solid and unchanging, they are in a constant state o flux, like other tissues in the body.
withdrawals outpace deposits. dep osits. However However,, osteoporosis is not inevitable. You can lose a certain amount o bone and still be in the normal range or bone density density.. At a certain point, however, i you keep losing bone, you will be at an intermediate stage o bone loss called osteopenia, or simply low bone density. I you do not manage to halt or slow the loss at this point, you may eventually cross the line into osteoporosis, in which porous bones become weak and susceptible to breaks or ractures. Tis report will examine both o these problems and explain the various measures you can take to help your bones, no matter which stage you are at. But first, to understand how and why osteoporosis occurs and what can be done to prevent and treat this potentially devastating ailment, it helps to know some basics about the living tissue that makes up the more than 200 individual bones o the body body..
Figure 1: Compact and trabecular bone
Two types of bone tissue Trabecular bone
Compact bone
Most bones in your body are composed of two types of tissue: compact bone and trabecular bone. Often, the compact bone— tightly packed tubes of bone tissue whose cross-sections resemble the rings of a tree trunk—forms the outer casing, while the trabecular bone, which is more porous, is found at the center.
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Te bones in your body contain two essential types o tissue. • Compact bone. As the name implies, compact bone tissue is densely packed. It is composed o units called osteons, which consist o tight plates wound into tubular orms that resemble rolled-up magazines (see Figure 1, at lef). A tiny blood vessel, or capillary, runs through the center o each osteon, supplying nutrients and oxygen. Osteons are arranged in stacks to orm a bone’s hard outer casing. In act, compact bone is sometimes reerred to as cortical bone, derived rom the Latin word “cortex,” meaning “bark” or “shell.” • Trabecular bone. Te second major type o material in your skeleton is called trabecular bone, meaning “like a little beam.” rabecular bone is www.health.harvard.edu
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composed o millions o tiny beams and plates that orm a lattice-like matrix (see Figure 1, page 2). It is less dense and spongier in consistency than compact bone and, or this reason, is sometimes known as spongy bone or cancellous bone (meaning “lattice-like”). Most bones contain a combination o compact and trabecular tissue, with compact bone orming the
Calcium carries a lot o weight in the body, both literally and figuratively. It’s the major component o the cement-like mineral, hydroxyapatite, that lends bones their strength. But it also plays a crucial role in other parts o the body. Buoyed along in the blood, calcium bustles in and out o cells, transmitting signals to nerves and muscles. In this capacity, it is vital or maintaining heart rate and blood pressure, as well
dense outer casing and trabecular bone filling the interior. Over all, the ratio o compact to trabecular bone in adults is about our to one, although the proportion varies greatly greatly rom bone to bon bone. e. Long, rregular egular bones, like those o the t he arms, legs, and ribs, consist primarily o compact bone. Irregularly shaped bones—such as the ends o the leg or arm bones, the spinal vertebrae, and the pelvis—consist mostly o trabecular bone. Why is this relevant? It helps explain, or example, why the spine is particularly part icularly vulnerable to osteoporosis. Not only is trabecular bone—the main constituent tissue in vertebrae—less dense than compact bone by its very nature. It is also metabolically more active, so when bones begin to lose density, trabecular bone grows weaker aster and thereore starts earlier in the progression toward osteoporosis. It is or this reason that trabecular bone in the spine is lost first, and why it’s important to see your doctor or a bone density test o the spine no later than age 65 in women and age 70 in men, or sooner i you have risk actors.
as regulating internal organs. Calcium is so important that when blood levels o this mineral drop below a certain threshold, the body raids the bones to compensate. Howev However, er, the amount o calcium required to maintain all these other unctions is slight—only about 1% o your body’s total calcium stores. Te rest—weighing about 2.25 to 4.5 pounds—is sequestered in your bones.
Bone remodeling
Tapping and replenishing calcium stores Te process by which calcium is removed rom bone is known as resorption, and it is perormed by special cells called osteoclasts. Teir sawtooth membranes enable them to attach to the surace o bone. Once attached, they use acids and enzymes to break down the bone’s matrix o collagen and minerals, releasing these materials into the bloodstream or reuse in other parts o the body (see Figure 2, page 4). 4 ). Tis recycling effort leaves tiny trenches in the bone. A bone-building process known as ormation— carried out by cells called osteoblasts—counterbalances resorption. Osteoblasts move into the trenches lef by the osteoclasts and release strands o collagen
Although compact and trabecular bone differ in structure, they are composed o the same basic material: a meshwork o protein fibers, called collagen. Te collagen matrix is inlaid with calcium and phosphate minerals, which are mixed with water to orm a hard, cement-like substance called hydroxyapatite. Smaller amounts o sodium, magnesium, and potassium are also present in the matrix. Calcium, however, however, is the main ingredient o bone. Te dynamic process by which bones take in or release this vital mineral is known as remodeling, or bone metabolism. Osteoporosis is the eventual result when bone remodeling gets out o balance, causing more calcium to leave the bones than is added.
into the void. Eventually, they become trapped in the web they have woven. Held by these moorings, they evolve into structural bone cells, or osteocytes. Calcium, phosphate, and other minerals carried in the bloodstream also accumulate in the web woven by osteoblasts. Te minerals coalesce into crystalline hydroxyapatite, and the ormation process is complete: the bone that was removed has been ully replaced. o maintain bone density, the body needs to keep a constant balance between bone production and breakdown. Enter the osteocytes—matur osteocytes—maturee osteoblasts that have become trapped within the bone matrix they helped construct. Osteocytes send out signals that oversee bone remodeling. Tey direct osteoclasts to
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Osteoporosis
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Figure 2: The cycle of bone construction and demolitio demolition n A
B
Osteoclast
Trenches left by osteoclasts
C
D
Osteoblast Osteocyte
Another key player in bone health is parathyroid hormone, which is secreted by small glands behind the thyroid. Te glands release parathyroid hormone when the level o calcium in the blood alls below the amount needed by the body’s cells. In response, the digestive system absorbs more calcium rom ood and the kidneys excrete less calcium in urine, both o which help to raise blood levels o calcium. Parathyroid hormone also stimulates the osteoclasts to break down bone, releasing calcium into the bloodstream. When the blood levels are adequate, the production o parathyroid hormone alls.
The life cycle of bone Bone is constantly being constructed and demolished. During resorption (A (A), cells known as osteoclasts break down bone, releasing calcium into the bloodstream.
Bone remodeling is a lielong process. At first, building outpaces demolition (resorption). Later in lie the ratio is reversed. In the middle—earlier than most people realize—you reach peak bone mass, the maximum bone density you will achieve.
The trenches that are left behind (B (B) are then filled in by construction cells known as osteoblasts.
break down bone and osteoblasts to orm new bone, thereby maintaining a kind o balance or equilibrium within the bones.
The early years During the first 20 years o lie, the body builds new bone more quickly than it removes old bone. By the late teens, most bone ormation has already occurred. In act, by age 20, most women have built 98% o their skeletal mass. Over the next decade, building slows, but still outpaces resorption. By age 30, most men and women reach their peak bone b one mass (see Figure 3, page 5). In an ideal world, you will have built strong bones early in lie. But even ii you haven haven’t, ’t, you
Other key players Te remodeling process releases stored calcium or critical unctions elsewhere in the body, and it also keeps your skeleton resh and healthy by replacing old bone with new. Tis important task in the body’s housekeeping scheme requires more than just osteoclasts, osteoblasts, and osteocytes. It also takes a sizable squad o hormones and other substances to carry out bone ormation. For example, vitamin D (which is actually a hormone) plays a pivotal role, limiting withdrawals o calcium rom bone by enhancing calcium absorption rom ood in the intestines into the bloodstream.
should not be discouraged. It’s never too late to adopt bone-preserving habits. Te density o bones at their peak varies rom person to person. Heredity, liestyle, and medical conditions all influence how much bone you’ll have in the bank when heavy withdrawals begin. It’s important to begin building this “rainy day und” early, when you have the most opportunity to influence your bone mass. Following are some o the actors that influence peak bone mass. Sex, race, and genes. In general, bone density is 30% higher in men than in women and 10% higher in blacks than in whites. Even so, there is wide varia-
The osteoblasts release collagen into these troughs and eventually evolve into structural bone cells, or osteocytes (C ( C). Once these osteocytes mix together with calcium, phosphate, and other minerals to form a cement-like substance known as hydroxyapatite, the process of replacing the lost bone is complete (D (D).
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Medications. Use o certain
Figure 3: Bone density through the ages Attainment of bone mass
S S A M E N O B
Consoli lid datio ion n
Age-related bone loss
Menopause
drugs may be accompanied by bone loss (see “Medical conditions and medications that can lead to bone loss,” page 7). oo much synthetic thyroid hormone taken or an underactive thyroid gland can weaken bones. Other drugs that
diminish bone strength include glucocorticoids, which are taken to control asthma and immune disorFracture threshold Women ders (see “6 ways glucocorticoids hinder bone ormation,” page 8), 0 10 20 30 40 50 60 as well as medications used to treat AGE (YEARS) breast and prostate cancers. Also, Bone formation outpaces resorption up to age 30, when both men and women reach their because several drugs that speed peak bone mass. Then the process reverses, leading to a plateau and finally a loss of bone bone loss are commonly given mass that occurs gradually in men but much faster in menopausal women. ater organ transplants, people Source: Compston JE. JE. Clinical Endocrinology, 1990. Endocrinology, 1990. who have had these operations are tion within these groups. Te difference may trace to at considerable risk o developing osteoporosis. several genes that influence bone mass, bone turnover, and bone loss. Middle age and beyond Diet. Nutrition early in lie strongly influences Among women, bone mass usually remains steady bone health in adulthood. Research indicates that until the onset o menopause, when bone is lost rapwomen whose diets contain the greatest amounts idly. But or many women, bone degeneration begins o calcium and vitamin D during childhood and in the years just preceding menopause (perimenoadolescence have denser and stronger bones during pause), as estrogen levels start to dip. While the pace o adulthood. Consuming enough calories is also vital: bone loss slows afer the first ew years o menopause, when girls and women have too little body at to sup- women continue to lose bone in the ollowing years. port menstruation because o anorexia or bulimia, In act, during the five to seven years afer menopause, their bones suffer and they are in greater jeopardy o women can lose up to 20% o their bone mineral denMen
developing osteoporosis. Exercise. Regular weight-bearing exercise contributes to peak bone density density.. Tis includes any activities that involve overcoming gravity’s pull, including weight lifing and other orms o resistance training, running, walking, aerobics, soccer, basketball, gymnastics, tennis, and gol. Exercise puts stress on bone, and bones respond by bulking up. However, or women, exercising exercising to an extreme can result in declining estrogen levels, amenorrhea (abnormal absence o menstrual periods), and eventually bone loss. Tis unhealthy situation is particularly common among young dancers, elite athletes, long-distance runners, and gymnasts. w w w . h e a l t h . h a r v a r d . e d u
sity (the measure o how densely the bones are packed with calcium and other minerals). Because androgen levels in men all off more gradually, bone loss usually begins later or them— typically in their late 50s—and progresses more slowly. Te main contributors to their bone loss are medical conditions and the general effects o aging. Men also start off with greater bone mass than women. By ages 65 to 70, men and women lose bone at the same rate, although more women than men are diagnosed with osteoporosis at all ages. And the process can be hastened by a variety o medical conditions and medications that are covered in the next chapter. Osteoporosis
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What causes osteoporosis?
W
hile a certain amount o bone loss is normal, not everyone develops osteoporosis. Many things
can cause osteoporosis. Some are actors you can change. Others are beyond your control. Bone loss begins when the cells that orm bone (osteoblasts) cannot keep pace with the cells that break down bone (osteoclasts). I you were to view a microscopic video o the process, you would see the osteoclasts going about business as usual, while the osteoblasts’ efforts all short. Although the trenches dug by the osteoclasts don’t get any deeper, neither are they refilled completely. As trenches accumulate, the bone becomes thinner, more porous, and weaker than it once was, leading to a condition called osteopenia that precedes osteoporosis. Tere are no symptoms associated with such bone loss. But i it continues long enough, leading to osteoporosis, bones will eventually become too weak to bear the load they were designed to carry. Te result is usually a racture o the t he wrist, hip, or spine. Doctors sometimes classiy osteoporosis as primary or secondary secondary,, depending on the cause.
Primary osteoporosis Te term primary osteoporosis is used to describe the t he most common orm o the disease, which is the consequence o a normal physiological process, such as menopause or aging. Menopause Postmenopausal osteoporosis occurs when declining estrogen levels in women lead to rapid bone loss. ypically, the process accelerates in the first ew years o menopause and then begins to level off. Te effects are most prominent in trabecular bone, which isn’t as dense as compact bone. Several actors may contribute to this process. A number o researchers are examining the roles 6
Osteoporosis
k c o t s k n i h T | d n u L p r o t n e m m A b o c a J ©
Although a certain amount of bone loss is inevitable, osteoporosis is not. Osteoporosis can be the result of menopause, aging, or certain drugs or medical conditions—or a combination of these.
o chemical regulators, such as interleukin-1, interleukin-6, interleukin6, prostagland prostaglandin in E2, and tumor necrosis actor, which appear to speed up bone resorption by spurring on osteoclasts as estrogen levels decline. Such research could someday lead to better drugs to prevent postmenopausal bone loss. Aging Gradual bone loss with aging may also lead to osteo-
porosis. In this case, the bone loss develops more slowly than postmenopausal osteoporosis and is usually not apparent until age 75 or later. As with all agerelated changes, it probably reflects several actors. Slowdown in bone formation. As described earlier, bone in older people is broken down more quickly than it is ormed. Reduced levels of calcium in the bloodstream.
With age, the intestines gradually absorb less calcium rom ood, and the kidneys seem to be less efficient at conserving calcium. Tus, less calcium reaches the bloodstream, and more calcium leaves the body in eces and urine, making it increasingly likely that the body will need to tap the t he calcium stored in bones. www.health.harvard.edu
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o make matters worse, most people consume less lem, many older adults consume ewer dairy products, D, so they take in less calcium in their diets as they age, urther straining which are ortified with vitamin D, their calcium reserves. Some older adults may avoid through their diets. Vitamin D plays a central role in dairy products i they have lactose intolerance (a the body’s absorption o calcium and in the process o reduced ability to digest milk sugar), which can pro- turning calcium into bone. I you don’t have enough absorb calcium, duce gas and abdominal discomort. Others may shun vitamin D to signal your intestines to absorb calcium-containing oods and supplements because o your body will break down bone to get the calcium it needs—no matter how much calcium you’re getting their constipating effects. Reduced vitamin D production. Te body’s production o vitamin D requently drops with age as well. Your skin cells use sunlight to produce the chemical raw material that the body needs to make vitamin D. Te liver and kidneys then convert this precursor into active vitamin D. However, people ofen spend less time in the sunlight as they grow older, so there is less o the raw material available—and in addition, the body becomes less efficient at converting this precursor to active vitamin D. Compounding the prob-
rom ood or supplements.
Secondary osteoporosis Te term secondary osteoporosis is used to describe osteoporosis resulting rom a medical condition or the use o certain medications. I you have one o these conditions or i you’re taking any o these drugs, talk to your doctor about what you can do to keep your bones healthy.
Medical conditions and medications that can lead to bone loss MEDICAL CONDITIONS
• Hyperthyroidism • Hypogonadism
• Acromegaly
• Ehlers-Danlos syndrome
• Alcoholism
• Emphysema
• Amyloidosis
• End-stage renal disease
• Androgen insensitivity
• Epilepsy
• Hypophosphatasia • Idiopathic scoliosis
• Ankylosing spondylitis
• Gastric bypass
• Inflammatory bowel
• Anorexia
• Gastrointestinal surgery
• Athletic amenorrhea
• Gaucher’s disease
• Bulimia
• Glycogen storage diseases
• Calcium deficiency
• Heart failure
• Celiac disease
• Hemochromatosis
• Chronic metabolic acidosis
• Hemophilia
• Cushing’s syndrome
• Homocystinuria
• Cystic fibrosis
• Hypercalciuria
• Depression
• Hyperparathyroidism
• Diabetes (types 1 and 2)
• • • •
disease Klinefelter’s syndrome Leukemia and lymphoma Liver disease Lupus
• Pancreatic disease • Panhypopituitarism • Porphyria • Post-transp Post-transplant lant bone • • • • •
disease Premature ovarian failure Primary biliary cirrhosis Renal tubular acidosis Rheumatoid arthritis Sarcoidosis Sickle cell disease Systemic mastocytosis Thalassemia Thyrotoxicosis Turner’s syndrome
• Malabsorptive disorders • Marfan’s syndrome
•
• Multiple myeloma • Multiple sclerosis
• •
• Hyperprolactinemia
• Muscular dystrophy • Osteogenesis imperfecta
• Anti-androgens
• Cyclosporine (Neoral,
• Heparin therapy (long-term)
• Selective serotonin
• Anticonvulsants
Sandimmune, others) • Depot medroxyprogesterone (Depo-Provera) • Glucocorticoids • Gonadotropin-releasing hormone agonists
• Lithium (Eskalith, Lithobid,
reuptake inhibitors (SSRIs) • Tacrolimus (Hecoria, Prograf, others) • Thiazolidinediones (TZDs) • Thyroid hormone (in excessive doses)
• •
MEDICATIONS
• Aromatase inhibitors (Arim-
idex, Aromasin, Femara) • Barbiturates • Canagliflozin (Invokana)
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others) • Loop diuretics • Methotrexate (Rheumatrex, Trexall, others) • Proton-pump inhibitors (PPIs)
Osteoporosis
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Medical conditions that cause bone loss Certain medical problems can affect bone health— some severely. For example, congenital disorders that affect bone mass over a lietime—such as Maran’s syndrome, Ehlers-Danlos syndrome, or osteogenesis imperecta—increase the risk or osteoporosis. Some chronic conditions, including anorexia, certain cancers, liver disease, and disorders that affect mineral
strength and possibly raise the risk o suffering a harmul racture. In an otherwise healthy person, such medications might have a small effect that doesn’t unduly raise racture risk. But i you have already begun to lose bone or you’ve been diagnosed with osteoporosis, the effects o these drugs may be enough o a concern to warrant discussing them with your doctor. You and your doctor can decide whether you
absorption, may also have an impact (see “Medical conditions and medications that can lead to bone loss, loss,”” page 7). So does primary hyperparathyroidism, a condition in which people have abnormally high levels o parathyroid hormone. Tis hormone helps regulate the amount o calcium in the blood. Excessive levels spur the removal o calcium rom bones and increase the amount o calcium in the blood. In turn, the kidneys ofen try to compensate or the extraordinarily high blood levels o calcium by excreting large amounts o it in the urine. Every year year,, approximately approximately 100,000 new cases are detected, the majority o them in women. Ofen, this condition has no symptoms and is ound only when a routine blood test shows high calcium levels. However, as primary hyperparathyroidism advances, it can cause kidney stones, muscle weakness, atigue, and eventually osteoporosis.
should stay on these drugs or switch off them based on your bone health and overall health. Researchers have ound a definitive link between the ollowing drugs and bone loss: Glucocorticoids. Te most common cause o drug-related osteoporosis is the use o glucocorticoids, also known as corticosteroids (see “6 ways glucocorticoids hinder bone ormation,” below lef). Tese drugs, which include prednisone, are ofen prescribed to treat conditions such as asthma, rheumatoid arthritis, and chronic obstructive pulmonary disease. Glucocorticoids are also used to prevent rejection ater organ transplantation. Although inhaled corticosteroids, which are an integral part o asthma treatment, are less likely to cause bone loss than oral corticosteroids, they can still weaken bones, especially at high doses. Aromatase inhibitors (for women). Many women with breast cancer have benefited rom a class o drugs called aromatase inhibitors, which block estrogen production. Tese drugs include anastrozole (Arimidex), exemestane (Aromasin), and letrozole (Femara). Tese drugs reduce the chance o cancer coming
Medications that cause bone loss A variety o medications, both prescription drugs and those available over the counter, can affect bone
6 ways glucocorticoids hinder bone formation These medications—including prednisone, methylprednisolone, and hydrocortisone—do the following: • interfere with the
body’s ability to absorb calcium from food • increase the amount of
calcium lost in the urine • fuel bone-destroying
osteoclasts •
hamper bone-building osteoblasts
8
Osteoporosis
• possibly trigger the body
to produce too much parathyroid hormone, which removes calcium from bone stores • reduce the production of
estrogen in women and testosterone in men.
back in women whose cancers are “estrogen positive,” meaning they tend to grow in response to estrogen. Aromatase inhibitors are more effective than tamoxien (Nolvadex, Apo-amox, amoen, amone), a leading cancer drug, in preventing cancer recurrence afer treatment. But because estrogen slows bone loss, lowering levels o this hormone with an aromatase inhibitor can harm bone health. As a result, women taking these drugs are at greater risk o spinal and other ractures. Androgen-su ppressing drugs (for men). Certain Androgen-suppressing men with prostate cancer undergo androgen depri vation therapy with a variet varietyy o different medications that lower levels o male hormones to suppress www.health.harvard.edu
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the cancer. But at the same time, androgen deprivation therapy can put them at greater risk o bone loss and ractures. In one study, about 20% o men given this therapy who survived or at least five years experienced a bone racture, compared with 13% o men who did not receive this treatment. Anyone being treated or prostate cancer with hormonal therapies should discuss the ramifications
ate, which does require acid or maximal absorption). Calcium citrate is ofen recommended or people taking PPIs long-term. Antidepressants. ts. Researchers have also uncover uncovered ed Antidepressan a possible association between reduced bone strength and a class o antidepressan antidepressants ts called selective serotonin reuptake inhibitors (SSRIs). Tese drugs may contribute to bone loss by enhancing the effects o osteoclasts in
to bone health and how to prevent bone loss. Tis may involve having regular bone density screenings and ramping up appropriate preventive measures, such as calcium and vitamin D supplementation, weight-bearing exercise, and possibly medication to prevent bone loss. Medications that might cause bone loss Te ollowing drugs may cause bone loss, although the effect has not been proved yet. Organ transplant drugs. Some medications, such as cyclosporine, that are used to prevent organ rejection afer transplants may also urther bone loss. People using any o these medications should be vigilant about protecting their bones. Tey should pay special attention to diet and exercise and consider other steps to prevent bone loss and ractures. Proton-pump inhibitors (PPIs). his popular class o medications, used to reduce stomach acid, may erode bone strength and increase the risk o ractures. (Omeprazole, marketed as Prilosec, is one o the best-known PPIs.) By reducing stomach acid, PPIs may also impair the absorption o calcium rom
triggering bone turnover. However, the link is ar rom certain. Although people who use SSRIs seem to have a modestly higher risk o ractures, it’s not possible yet to show a definite cause-and-effect connection. In the meantime, i you are taking these medications longterm at your doctor’s recommendation, you may want to discuss whether there is more you could do to protect yoursel against ractures, such as being screened or low bone density or increasing your calcium, vitamin D, and exercise. Diuretics. Diuretics, or “water pills,” make the body excrete water and salt. Tey are ofen used to treat high blood pressure. One type, called loop diuretics, causes the kidneys to release more calcium. Commonly prescribed loop diuretics that have this effect include ethacrynic acid (Edecrin) and urosemide (Lasix). Several studies have shown that people who take loop diuretics have slightly lower bone density in racture danger zones like the hip, and a greater overall racture risk. Diabetes drugs. In the all o 2015, 201 5, the FDA added a new warning to the label o canagliflozin (Invokana), which is used to lower blood sugar in people with type
ood, potentially leading to weaker bones and a greater risk o bone ractures. Research to date suggests that the effect, i it is real, is modest, though not all studies agree. However, in a person already at risk o low bone density or ractures, long-term use o PPIs could pose a legitimate concern. I you’re at risk or ractures and you use a PPI or heartburn or to prevent ulcer flare-ups, ask your doctor how to counterbalance the effect o the PPI. I you take calcium supplements, you may want to switch to a product with calcium citrate, which does not require stomach acid or absorption (unlike calcium carbon-
2 diabetes. Canagliflozin belongs to a class o drugs called sodium-glucose cotransporter-2 (SGL2) inhibitors, which also includes dapagliflozin (Farxiga) and empagliozin (Jardiance). Doctors have noticed bone ractures, as well as decreases in the bone density o the hip and lower spine, in people taking canagliflozin. Another class o diabetes drugs called thiazolidinediones (ZDs), which includes pioglitazone (Actos) and rosiglitazone (Avandia), has also been linked to increased bone loss and racture risk. Beore you start taking one o these drugs, it may be worth discussing the bone risks with your doctor.
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Osteoporosis
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9
Know your risk factors
C
ertain actors make you more vulnerable to developing the bone weakening that can lead to rac-
tures. Some o these risk actors—like age and amily history—aren’t within your control. Others are modifiable with some relatively simple liestyle changes. I you haven’t yet been diagnosed with osteoporosis, use these risk actors as a guide to launching a discussion about bone density testing with your doctor. I you have already been diagnosed, addressing the liestyle actors you can change can help preserve the bone strength you still have.
Risk factors you can’t control Tough you can’t change these actors, being aware that you have them can enable you to discuss bone preservation steps with your doctor doctor.. Gender. For a variety o reasons, women are at higher risk than men, though men can develop it, too (see “Osteoporosis risk in women,” page 11, and “Osteoporosis risk in men, men,”” page 112). 2). Aging. Advancing years inevitably bring a higher risk or osteoporosis—particularly or women. According to the Centers or Disease Control and Pre vention (CDC), 16% o o wom women en and 4% o men aages ges 50 and over have osteoporosis as measured at the neck o the emur (near where the upper leg bone connects to the hip) or the lumbar spine (the vertebrae o the lower back). People in this age group also show signs o low bone strength in the spine or emoral neck, making them more likely to eventually develop osteoporosi osteoporosis. s. Family history of the disease. Te genetic traits you inherit also strongly influence your risk. Between 70% and 80% o bone structure is genetically determined. Both men and women whose first-degree amily members (parents, siblings) have had ractures are at greater risk. In act, a woman whose mother or ather had a racture is at twice the risk o a break— regardless o her measured bone density. 10 Osteoporosis
hig hRace. Caucasian and Asian women ace the highest osteoporosis risk, because their bones tend to be thinner and smaller than those o Arican American and Hispanic women. Asian women also tend to have a lower dietary intake o calcium, because many o them are lactose intolerant. Yet surprisingly, despite having thinner bones, Asian women are less likely to racture a hip than white women. Tis lower risk may be due to anatomical differences in the hip bone.
Risk factors you can control A poor diet, lack o exercise, smoking, and alcohol use can all hasten the onset o osteopenia or osteoporosis as you age. I you’ve already been diagnosed with bone loss, addressing these risks can help protect and preserve the integrity o your bones or as long as possible. Inadequate calcium and vitamin D levels. Inadequate intake o calcium rom your diet—as well as conditions that may interere with calcium absorption by the intestines—leads to lower calcium levels in the blood. Te body compensates by releasing calcium rom the bones, which weakens them. Your
4: A A look look at osteo osteoporoti poroticc bone bone Figure 4:
The photograph at left shows a microscopic view of bone b one from adenser woman who sufferatfrom Her bone is than thedoes bonenot shown right,osteoporosis. which is from a woman with osteoporosis. (The arrow points to a microscopic fracture.) www.health.harvard.edu
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body needs vitamin D to properly absorb calcium, so adequate amounts o this vitamin are also necessary. Sedentary lifestyle. When you are at rest, bone ormation slows; when you are physically active, bones bulk up and become stronger. Te research to date suggests that leading a physically active lie can decrease the risk o having a racture in the spine or hip by 30% to 50%.
Figure 5: Fracture risk
Smoking. Smokers tend to lose bone aster than
nonsmokers. Smoking may both interere with the absorption o calcium and lower the amount o boneprotective estrogen the body produces. A number o studies, some o them quite large, have ound that men and women who smoked were at greater risk o breaking a hip or other bone. In act, a report rom the U.S. Surgeon General on osteoporosis noted that smokers are 55% more likely than nonsmokers to break a hip. Excess alcohol consumption. Te amount o alcohol you drink can affect your bone health. Alcohol may interere with the body’s ability to convert inactive vitamin D into its active orm. It also appears to hamper bone ormation and increase losses o calcium and magnesium rom the body. Excessive drinking may be accompanied by poor nutrition and an increased tendency to all. People who consume more than two drinks per day may be at moderately higher risk o low bone b one density and ractures, compared with nondrinkers. Medications. In addition, people who take t ake certain drugs that contribute to bone loss may be at greater risk or osteoporosis. I you have a condition or you’re taking a medication known to affect bone density density,, talk to your doctor about what steps you may need to take to keep your bones healthy.
Osteoporosis risk in women Women are more likely than men to develop osteoporosis because they have smaller skeletons, their bone loss begins earlier and occurs more rapidly, and they have a lower peak bone density to begin with. About 80% o the 10 million Americans with osteoporosis are women. Te Study o Osteoporotic Fractures— a landmark National Institutes o Health study o almost 10,000 women ages 65 and older—ound that, w w w . h e a l t h . h a r v a r d . e d u
▲
FOR WOMEN
50% risk: One out
of two women over age 50 will have an osteoporosis-related fracture in her lifetime.
▲
FOR MEN
25% risk: One out
of four men over age 50 will have an osteoporosis-related fracture in his lifetime.
on average, bone mass ell by approximately 5% every five years in women afer age 65. he study looked at characteristics that are significantly more common among women who have osteoporosis. ogether with other research, it provides a good idea o the actors that can predispose certain women to osteoporosis. Tese include the risk actors below, as well as the list o general risk actors above. alk to your doctor about your risk and what, i anything, you should do about it, including having a bone density evaluation. Small-boned, thin women tend to have lower bone density and a higher risk o ractures. It may be because their bones are smaller, but the science doesn’t give us a definite answer on this point. In the Study o Osteoporotic Fractures, women 65 and older with the smallest body size had twice the rate o hip racture (10 in 1,000) compared with the rate among the largest women in the study (five in 1,000). Because estrogen slows bone resorption, women who are past menopause and those who have had their ovaries removed are at higher risk. So are younger women who have too little body at (sometimes because o excessive exercise, anorexia, or bulimia) and consequently too little estrogen to menstruate regularly. Te National Osteoporosis Foundation recommends routine dual energy x-ray absorptiometry Osteoporosis
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11
(DEXA or DXA) testing or women starting at age 65 to measure bone density. (For a more complete list o screening guidelines, see “Who should be screened?” on page 16.)
Osteoporosis risk in men It is a persistent misperception that osteoporosis is a “women’s disease.” Although bone loss strikes women younger and harder, men, too, are at significant risk o low bone density and the harmul ractures that can ollow. According to the National Osteoporosis Foundation, two million American men have osteoporosis and about 12 million more are at risk. Each year, about 80,000 men break a hip—and when they do, they are two to three times more likely to die o complications rom their injuries than women are. Nonetheless, men constitute only 20% o Americans with osteoporosis. wo actors make men less vulnerable than women to bone loss: they have greater bone density at maturity maturity,, and tthey hey experience a more gradual decline in hormone levels. When men
Online tool estimates your risk
I
f you have five minutes and access to the Internet, you can estimate your risk of developing osteoporosis at www.diseaseriskindex.harvard.edu.. This tool, developed www.diseaseriskindex.harvard.edu by the Harvard Center for Cancer Prevention, also helps you gauge your risk of heart disease, stroke, cancer, and diabetes. There’s a separate quiz for each disease, and you can choose which one you would like to complete. For each quiz, you answer some questions about your lifestyle and health history. history. The The questions are focused on proven risk factors for each disease. Once you’ve completed the questionnaire, your personal risk is calculated and compared with the average risk for a person of your age and sex, so you can see if you are more or less likely than average to develop these diseases. Even better, better, you’ll get information on what you are already doing to lower your risk and find out what more you can do.
12 Osteoporosis
under age 75 develop osteoporosis, it’s ofen because o an underlying health condition. In these cases, treatments address the condition or conditions that are responsible. But “less vulnerable” does not mean “invulnerable,” and the reason comes right back to declining sex hormones. Experts believe that age-related declines in testosterone levels may cause bone loss. Men also produce estrogen (though in smaller quantities than women), and declining estrogen with aging may be as significant or bone loss as low testosterone. In the Osteoporotic Fractures in Men Study, which involved over 2,400 men 65 and older, men who had low levels o both testosterone and estrogen were more likely to have osteoporosis than men with normal levels o these hormones. Researchers have also ound that men with low hormone levels are more likely to racture a hip. Te National Osteoporosis Foundation recommends routine DEXA testing or men starting at age 70 to measure bone density. Men ages 50 to 69 should also be tested i they have risk actors or osteoporosis, such as a history o a previous racture, low body weight, and smoking. In 2012, the Endocrine Society issued a clinical practice guideline that also recommended the same level o osteoporosis screening or men. However, the U.S. Preventive Services ask Force, Force, an independent panel o experts, concluded conclud ed that “the current evidence is insufficient to assess the balance o benefits and harms o screening or osteoporosis in men.” Tere is one thing that all experts agree on, however: men should protect their bones by ollowing the same liestyle recommendations suggested or women. Tat means engaging in regular weightbearing exercise, getting adequate amounts o calcium and vitamin D rom ood and (i needed) neede d) supplements, and avoiding habits known to deplete bone mass, such as smoking and drinking excessive amounts o alcohol. Tese habits will help maintain a solid reserve o bone mass to ward off ractures later in lie.
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The consequences of osteoporosis
O
steoporosis was once known as a silent disease because it gives no warning signs as it gnaws away
at bones. Eventually, it would make itsel known when a break occurred without due cause, perhaps triggered by something as innocent as a sneeze. Although any bone can be affected, most breaks related to osteoporosis occur in one o three sites: the hip, the spine, or the wrist (see Figure 6, below). Fractures at these sites, particularly in women who are past menopause, are most common because these regions contain relatively high proportions o trabecular bone and are thereore especially vulnerable to the effects o bone loss. Osteoporotic ractures exact a high toll, leaving some people in pain while stripping others o their ability to perorm everyday activities or to move around independently. Tree in five people who break a hip because o osteoporosis will never ully regain their previous level o unctioning. Many people become so earul o breaking another bone that they limit their activities, which causes them to eel helpless, isolated, and depressed. Research has shown
Figure 6: Fractures by site 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0
Spine Hip
Wrist
Pelvis
Other
Osteoporosis-related fractures reported in United States annually Source: National Osteoporosis Osteoporosis Foundation, Foundation, 2008. w w w . h e a l t h . h a r v a r d . e d u
that ractures in the spine, hip, and emur have the greatest impact on quality o lie.
Hip fractures About one in seven osteoporosis-related ractures occurs at the hip. ypically, these are the most serious types o osteoporotic racture. Hip ractures usually involve the neck or the intertrochanteric region o the thighbone (see Figure 7, page 14). Breaks can also occur in bones o the pelvis. Te impact o a hip racture on someone’s lie and activity level usually depends on the state o the bone and on the person’s physical condition. At best, the breaks are temporarily immobilizing, requiring confinement to bed or a wheelchair wheelchair.. Surgery is usually needed but may not be easible because o other disorders, such as heart or lung disease, which increase the risk or complications ollowing an operation. As a result, the damaged bone ofen heals badly, resulting in permanent disability. he injury oten has devastating eects on mobility and independence. Six out o 10 people who break a hip never ully regain their ormer level o independence. Some are permanently less able to perorm ordinary daily activities, such as dressing themselves or rising rom a chair chair.. Even walking across a room may be difficult. Tese changes in mobility and daily unctioning can make it necessary to seek home health care or to move to a acility that can provide care. Hal o the people who suffer a hip or spine racture will need assistance walking, and one in our will need long-term nursing home care. While people seldom die directly rom a hip racture, this injury and its accompanying medical problems can trigger a downward spiral in health. Complications, such as pneumonia or blood clots, that result rom the racture itsel or surgery to treat it are sometimes atal. One in five people who have a hip Osteoporosis
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13
Figure 7: Common hip fractures
A
Most hip fractures occur at the neck of the femur, or thighbone—also known as the femoral neck (A), or at the intertrochanteric B
region ( ). Each year there are nearly 300,000 hip fractures from osteoporosis in the United States. Fracturing a hip can have serious consequences, such as impairing the ability to walk or to perform simple everyday chores.
B
racture dies in the first year afer the injury. Te risk o death is 10% to 20% in the first six months afer a racture in the hip or spine. Fractures are particularly deadly among nursing home residents and people with cognitive impairment or other health issues. Te risk o death also disproportionate disproportionately ly affects those ages 80 and older, who are 10 to 15 times more likely to racture a hip than people 60 to 65. Tose who do survive may have trouble living on their own. But there is some encouraging news about hip ractures, too. According to a recent study, the number o hip ractures among people in the Medicare system is declining. Tis trend is probably in part due to the increased use o medications to prevent bone loss. Although the death risk or people who’ve suffered a racture may also be going down, the dangers o hip racture remain a powerul incentive to do all you can to preserve your bone health.
Spinal fractures Fractures in the spine are much more common than hip ractures (see Figure 6, page 13). Unlike hip ractures, spinal ractures ofen occur without a traumatic 14 Osteoporosis
cause like a all. Even without the added trauma, t rauma, these injuries can be quite debilitating. Simple acts o daily lie, such as bending over, twisting, coughing, or liting, can be enough to collapse a vertebra weakened by osteoporosis. In such cases, the bones o the spine, which consist primarily o trabecular bone, aren’t broken in the usual sense o the term. Rather than being snapped like twigs— as in the case o a broken arm or leg—the vertebrae are compressed, in the same way that a paper cup would be flattened when stepped on. Figure 8 (see page 15) compar compares es compressed and normal vertebrae and shows the effects o compr compression ession ractures on the spine. Vertebral ractures can cause a loss o height and, more seriously, a rounding o the back known as dorsal kyphosis, or dowager’s hump. Compression ractures may be accompanied by pain that is sharp, dull, intense, or radiating around the side. Pain may also come rom spasms in the muscles at months, the sidesofen o the spine. Itafer maythe come andsits go or several recurring person in the same position or a long time. Discomort rom ractures can usually be relieved with pain medications such as aspirin or ibuproen (Advil, Motrin).
Can hip protectors prevent breaks?
A
quick online search will turn up plenty of hip pads that are touted as a way to help prevent a hip fracture if you fall. The pads, which consist of a stiff plastic shield underlaid with foam padding, are meant to be strapped onto the hip. For those living in nursing homes, h omes, who are at high risk of a fracture, some studies suggest hip protectors may reduce injuries. But systematic reviews of the best research available have failed to prove that providing hip protectors to older adults living independently reduces the incidence of hip fractures. The main challenge is getting people to wear the hip protectors consistently and properly. The pads can be uncomfortable and awkward, and many people just don’t like wearing them. Also, people may fall in circumstances in which they would not be wearing the pads, for example in the bath or shower. But if worn consistently by people at risk of hip fracture, these pads could theoretically be of benefit.
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In many instances, vertebral ractures cause little or no pain. Te principal clue that they have occurred is a gradual shrinkage or stooped posture. Te amount o height lost and the degree o deormity will depend on the number, location, and severity o the compression ractures. However, narrowing o the cushion-like disks between vertebrae—which ofen occurs as part o aging—may also cause deormity and
becomes progressively more distorted. Te upper body is thrust down and orward. Te abdominal muscles sag, and the space between the ribs and pelvis closes. Te chest wall becomes cramped, and the abdominal organs are compressed and pushed orward. Breathing may become difficult and digestion may be impaired, leading to bloating and heartburn. Severe spinal deormity affects mobility almost as
significantly as a hip racture. Since walking erect is a loss o height. Most people who have vertebral ractures have difficult, a cane or walker becomes essential. Riding one or two, most commonly in the thoracic, or mid- in a car or more than a ew minutes can be very back, region. While one or two mid-back compression uncomortable. wo procedures—vertebroplasty and ractures may produce only a slight loss o height, many kyphoplasty (see page 50)—can stabilize compressed improve ve da daily ily unctioning. can prooundly affect your appearance, mobility, and vertebrae, relieve pain, and impro health. As the number o ractures increases, the spine
8: A A look look at norm normal al and and compre compressed ssed Figure 8: vertebrae
Vertebrae with fractures
Wrist fractures Osteoporosis accounts or nearly 400,000 wrist ractures a year. Tese breaks are usually the result o an attempt to end break all.radius, Te orce thebone impact usually snaps the oathe the o long that runs rom the elbow to the thumb, ofen producing a characteristic break known as a Colles’ racture. Normally, afer a wrist racture occurs, the arm is immobilized in a cast, splint, or sling and allowed to heal, although surgery is sometimes needed. Wrist ractures usually mend completely. However, they can occasionally result in deormity and a loss o some unction that intereres with the ability to perorm everyday activities with ease.
Other consequences Normal vertebrae
Normal vertebrae are upright, but if several vertebrae collapse, it can cause a curvature of the spinal column known as dorsal kyphosis or dowager’s dowager’s hump. This condition can make it difficult to walk without a cane or walker and can interfere with proper breathing and digestion.
w w w . h e a l t h . h a r v a r d . e d u
Although trabecular bone b one loses strength more rapidly rapidly,, compact bone eventually becomes vulnerable as well. As osteoporosis advances, bones with a high proportion o compact tissue—such as the pelvis, tibia (shin), humerus (upper arm), and emur (thigh)—are ractured with increasing requency. Ribs may be broken rom the orce o a cough. Although the jawbone may not snap, it is not exempt rom bone loss. As the jaw becomes increasingly porous, it provides less support or the teeth anchored into it. Te result can be dental problems such as loose teeth and ill-fitting dental plates. Osteoporosis
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15
Detecting osteoporosis
I
n the past, osteoporosis was requently diagnosed only afer a bone racture. For many people, that
diagnosis came too late to be o much use. oday, osteoporosis can be detected earlier with a bone mineral density test. Such a test can also provide inormation regarding your risk o suffering a racture and can help you and your doctor monitor your progress i you’re taking bone-building medications.
Who should be screened? Screenings for osteoporosis are not routinely given to everyone; instead, they are done on a case-by-case basis. Experts are still debating who should receive bone density screening, and it remains unclear whether the benefits of tests such as dual energy x-ray absorptiometry (DEXA) justify the cost of testing everyone. Talk to your doctor about whether testing is right for you. Consider being screened if you are
DEXA scans for bone density Several technologies can assess bone density, but the most common is known as dual energy x-ray absorptiometry (DEXA).bones For this procedure, a machine x-rays through in order to calculate bonesends density.. Te process is quick, taking only five minutes. And sity it’s simple: you lie on a table while a scanner passes over your body (see Figure 9, below). While this technology can measure bone density at any spot in the body, it is usually used to measure it at the lumbar spine (in the lower back), total hip (a specific site in the hip near the
Figure 9: Scanning for osteoporosis
Dual energy x-ray absorptiometry is thephysicians most common method of detecting osteoporosis (DEXA) today. today. Most consider it the most accurate diagnostic procedure.
16 Osteoporosis
• a woman age 65 or older or a man age 70 or older • a postmenopausal woman under age 65 or a man age
50 to 70 with one or more risk factors for osteoporosis • a woman or man with a medical condition or taking a
medication that places you at high risk for osteoporotic fractures • a woman who is in menopausal transition who has specific risk factors that increase fracture risk (such as low body weight or a prior fracture) • a woman or man over age 50 who has fractured a bone • a woman or man who has taken glucocorticoids for at
least two months. However, it’s important to note that coverage varies However, among insurance plans. Some plans may refuse to pay for a DEXA scan. Others might specify how often you can have this test repeated. For example, Medicare will cover the cost of one bone density test every two years, or more often if your doctor deems it medically necessary. necessary. So that you don’t wind up footing the bill yourself, it pays to check with your plan first.
hip joint), and emoral neck (the top o the thighbone, or emur; see Figure 7, page 14). DEXA accomplishes this with only one-tenth o the radiation exposure o a standard chest x-ray and is considered the gold standard or osteoporosis screening—though ultrasound, which uses sound waves to measure bone mineral density at the heel, shin, or finger, is also used at health airs and in some medical offices. Te DEXA scan or ultrasound will give you a number called a -score, which represents how close www.health.harvard.edu
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you are to average peak bone density. Te World Health Organization has established the ollowing classification system or bone density: • I your -score is –1 or greater: your bone density is considered normal. • I your -score is between –1 and –2.5: you have low bone density, known as osteopenia, but not osteoporosis.
tebral racture assessment (VFA) uses the same type o x-ray as DEXA, but instead o measuring bone b one density, it shows the shape o the vertebrae. Te goal is to see i any o the vertebrae are deormed—a possible sign o racture. More vertebrae are scanned in VFA than in a traditional DEXA test or bone density. I the VFA shows that you have one or more ractures, you likely have severe osteoporosis and will need more
• I your -score is –2.5 or less: you have osteoporosis, even i you haven’t yet broken a bone.
aggressive treatment. VFA is recommended or • women ages 70 and older and men ages 80 and older with a -score o –1 or less at the lumbar spine, total hip, or emoral neck • women ages 65 to 69 and men ages 70 to 79 with a -score o –1.5 or less at the lumbar spine, total hip, or emoral neck • women and men ages 50 and older with risks such as a racture during adulthood, total height loss o 1.5 inches or more, recent height loss o 0.8 inches
fracture assessment Vertebral fracture assessment Because vertebral ractures are so common in older adults, and they ofen occur with wit h no symptoms to warn o their presence, the National Osteoporosis Foundation recommends vertebral imaging at the same time as the DEXA test or certain groups o people. A ver-
How likely are you to break a bone? Your Your FRAX score and more
W
hile bone mineral density tests can identify people who are at greater risk for fractures, they aren’t the only predictors. A tool developed by the t he World Health Organization calculates an individual’s real-life risk of suffering an osteoporosis-related fracture in the coming years. FRAX (fracture risk assessment tool) incorporates bone mineral density scores with other weighted risk factors to arrive at a percent probability that a person will break a hip or suffer another type of osteoporotic fracture such as a break in the vertebra, forearm, or shoulder within 10 years. Risk factors used are age, sex, height, weight, previous fragility fracture as an adult, parental history of hip fracture, current smoking, alcohol use (three or more drinks per day), glucocorticoid use for more than three months, rheumatoid arthritis, arthritis, and secondary osteoporosis. The FRAX score is measured in people whose bone mineral density is in the osteopenic range (T-score between –1 and –2.5). FRAX was developed to help physicians better identify highrisk individuals whose bone density is in the range of osteopenia. If you’ve had a bone density test or if you think you might have an increased risk of osteoporosis, you may want to ask your physician about calculating your FRAX score. The The tool is geared for doctors’ use, but you can find it online at www.shef.ac.uk/FRAX. www.shef .ac.uk/FRAX. Based in part on the FRAX tool, the National Osteoporosis Foundation recommends that doctors consider drug therapy for men and women ages 50 and over who meet one or more of the following criteria:
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• a previous hip or spinal fracture • a T-score T-score of –2.5 or less at the hip or spine • a T-score between –1 and –2.5 at the hip or spine together
with a 10-year FRAX-estimated risk of at least 20% for a major fracture or 3% for a hip fracture. ▼ Watch
for these red flags If you don’t know your bone density measurement or FRAX score, familiarize familiarize yourself with the factors that increase your chance of falling and breaking a bone. If any of the following red flags apply to you, discuss them with your doctor:
• low levels of physical activity • overall weakness and frailty • low muscle mass or impaired strength • advancing age • excessive alcohol use • a history of falls • balance problems • poor eyesight • taking medications (such as sedatives and blood pres-
sure drugs) that can cause dizziness, lightheadedness, lightheadedness, or impaired balance • hazards such as electrical cords or throw rugs cluttering
the walking paths around your house.
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or more, and recent or long-term glucocorticoid treatment.
Lab tests for bone turnover Your doctor may use bl blood ood and uri urine ne tests to check or secondary causes o osteoporosis. In addition, these tests can provide inormation about bone turnover, the rate at which old bone is being remodeled. Te tests measure substances called biochemical markers that are released during bone ormation and resorption. High levels o biomarkers associated with bone resorption can indicate high bone turnover turnover,, a red flag or declining bone health. A doctor might also order one o these tests to assess your response to treatment. For example, a
18 Osteoporosis
urine test revealing that bone turnover slowed afer you started taking an osteoporosis drug could be a sign that the treatment is working. Conversely, i tests show that the rate o bone turnover has remained the same or increased, it may suggest that the treatment is ineective (or that you are not taking your medication). Your doctor should find out what’s going on and determine the best course o action, which may include adjusting your dose or offering suggestions to ensure that you take your medicine as prescribed. Te bottom line on lab tests or bone turnover is this: Doctors don’t routinely use these tests to diagnose osteoporosis or predict racture risk—DEXA is the best tool or that job. But they may be helpul under certain circumstances when bone turnover needs to be assessed.
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Developing a plan of action
I
you’ve been diagnosed with osteopenia or osteoporosis, your doctor will help you develop a plan to slow bone destruction and even gain back some o the bone you’ve lost. Tat plan will likely include our main strategies: diet, exercise, medication, and all prevention. You’ll find more detail on these strategies in later chapters chapters..
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If you have osteopenia (T-score (T -score between –1 and –2.5) According to your -score, your bone density is lower than normal, but your racture risk isn’t as high as thatmedicines o someone Youwon’t may not need at with this osteoporosis. point, and you necessarily progress to osteoporosis. A ew liestyle interventions should slow down the rate o bone loss, although althoug h they won’t help you regain what you’ve already lost. o protect bones, your doctor will likely suggest the ollowing: Exercise. Te stress on bones rom weight-bearing exercise causes your body to keep reinorcing bone. Staying active slows bone loss, strengthens the muscles that support your skeleton, and improves
Even if you are at risk for osteoporosis, there there are steps you can take to help protect your bones. Start by getting plenty of weight-bearing exercise and sufficient calcium and vitamin D.
your coordination and balance so you’re less likely to all. A combination o strength training (weight training) and weight-bearing exercises (walking, tennis, stair climbing) is ideal or preserving bones. Get enough calcium and vitamin D. Tese nutrients are important or both all and racture prevention. Ask your doctor whether you can get enough calcium and vitamin D rom your diet alone or i you need to take a supplem supplement. ent. Quit smoking. Tis habit, which is also bad or your heart, lungs, skin, and other organs, can increase your racture risk. Ask your doctor about nicotine replacementt products, medicines, and other strategies replacemen to help you kick the habit.
Possibly take medicine. Your Your doct doctor or may recom-
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Don’t drink too much alcohol. Excess alcohol
consumption can decrease bone mass, and heavy alcohol use can also make you more apt to all. Take additional measures to help avoid a fall.
Remove clutter that might cause you to trip, and be careul about using sedative medications and sleep aids that can make you uneasy on your eet. mend an osteoporosis drug or treating osteopenia i all three o the t he ollowing apply to you: • You’re age 50 or older. • Your -score is between –1 and –2.5 at the hip or spine. • You have a 10-year FRAX-estimated risk o at least 20% or a major racture or 3% 3 % or a hip racture.
If you have osteoporosis (T-score (T -score –2.5 and below) Once you’ve been diagnosed with osteoporosis, your doctor will likely start you on a medicine such as a Osteoporosis
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bisphosphonate, SERM, monoclonal antibody, or hormone (see “Protecting your bones: Medication,” page 39). Osteoporosis drugs can help you maintain bone density and in some cases improve it. Your doctor will continually reassess your bone density to determine how well the medicine is working and how long you should stay on it. Just because you start on medication, however, doesn’t mean you should abandon liestyle inter ventions. Although diet and exercise won won’t ’t reverse bone loss once you’ve been diagnosed with osteoporosis, they can slow it. Continue with all o the liestyle interventions listed above—get enough calcium and vitamin D, do regular weight-bearing and strengthening exercises, avoid smoking and excess alcohol consumption, consumption, and reduce your all risks.
If your bone density is normal
Check your calcium and vitamin D levels. Meet-
ing the recommended intake or these nutrients is a good start. But in addition, it’s wise to have blood tests or both. Calcium tests are are ofen part o standard bloodwork, but you may have to ask or a vitamin D test. Te level should be at least 30 ng/ml. Re-evaluate your exercise regimen. Exercise not only builds bone but also increases strength, flexibility, and balance. Now is a good time to incorporate weights into your routine, i you haven’t already been using them (see the Special Section, “Strength training and balance exercises or bone health,” page 34). Discuss preventive medications with your doctor. Many medications can help prevent osteoporosis
(see “Protecting your bones: Medication,” page 39). Your doctor can help you determine which one may be best suited or you. If you are 65 or older
While basics o protecting your bones—such as At point, has tapered off or women. But getting the enough calcium and engaging in weight-bearorthis men, bonebone loss loss is speeding up. Regardless o your ing exercises—remain the same throughout your lie, sex, you are still losing bone as you age. All o the t he prethere are different actors to consider as you get older. vious suggestions or bone maintenance maintenance still apply apply.. In addition, consider these options. If you are a woman at menopause Increase your calcium intake and get plenty I you are a woman in the early years o menopause, of vitamin D. Te recommended intake o calcium is you are probably in the stage o your greatest bone 1,200 milligrams (mg) or everyone in this age range. loss. All o the recommendations above apply, and you Make sure that you accompany it with 800 to 1,000 should do the ollowing as well. international units (IU) o vitamin D. Assess your risk. I you have reason to believe Keep up your exercise routine. In addition to you’re at elevated risk or osteoporosis (see “Know strength training, work on balance exercises or tai chi your risk actors,” page 10), talk to your clinician about having a bone density evaluation. I you have conditions or take medications that reduce bone mass (see “Medical conditions conditions and medications that can lead to bone loss,” page 7), ask your doctor what you can do to counteract these effects.
20 Osteoporosis
to lessen the likelihood o alling. Consider medication. Some drugs are used or osteoporosis prevention and treatment, while others are or treatment only (see able 6, page 44). You may want to talk to your doctor about whether you should take a preventive medication and, i so, which one.
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Protecting your bones: Nutrition
A
nutritious diet is just as important in later lie as it was when your mother urged you to “drink your milk” to strengthen your bones. Along with exercise, nutrition is a cornerstone o bone health—and general health, too. Even i you’ve been lax about eating a healthy diet in the past, it’s never too late to start making positive changes. Although oods that are rich in the bonebuilding nutrients calcium, vitamin D, and vitamin K won’t won ’t reverse osteopenia or o osteoporosis, steoporosis, the theyy can help preserve the bone you have and keep you healthier over all. Te ideal way to get these and other essential nutrients is through ood, but i you’re a little short, supplements may helpor you get theD,recommended amounts—particularly vitamin which can be hard to get enough o in your diet.
Calcium and vitamin D
Table 1: Recommended daily calcium and vitamin D intake in adults
The Institute of Medicine gives recommended intakes for both calcium and vitamin D. However However,, its recommendations for vitamin D are lower than those of the National Osteoporosis Foundation, which are listed in Table 4 (page 26). SE X /AGE
C A LC I U M
V I TAMIN D
19 to 50
1,000 mg
600 IU
51 to 70
1,200 mg
600 IU
71 and older
1,200 mg
800 IU
19 to 50
1,000 mg
600 IU
51 to 70
1,000 mg
600 IU
71 and older
1,200 mg
800 IU
Women
Men
Source: Institute of Medicine. Medicine.
Calcium and vitamin D have long been recognized as essential to bone health, as well as other important unctions in the body. Calcium provides the building material or strong bones. Vitamin D helps your intestines absorb calcium into the bloodstream, which delivers it to your bones, muscles, and other body tissues.
still being worked out, experts disagree on how much o these nutrients we need at different stages o lie. For this reason, the U.S. and Canadian governments asked the Institute o Medicine (IOM), a group o distinguished physicians and researchers, to review
Experts agree that people need calcium and vitamin D to maintain bone health. Yet whether we should increase our intake expressly or the purpose o preventing ractures is a little more controversial. wo 2015 studies in the journal BMJ ound that adding calcium to the diet, whether through ood or supplements, increases bone density by only a minimal amount, which is unlikely to translate into a noticeably reduced racture risk. Tis is why, or people with existing osteoporosis, nutrition is only one part o a strategy that also includes medica medication tion to strengthen bones and prevent ractures. In part because the beneits o calcium and vitamin D on bones and other aspects o health are
the evidence available and come to a consensus on basic daily requirements or these two vital nutrients. Te 14-member IOM panel examined more than 1,000 studies and listened to testimony rom various experts. Te panel weighed the evidence or a range o health benefits—not just or bone health, but also or reproductive health, immune and mental unction, and reduced risk o cancer, heart disease, and diabetes. One key outcome o the review were new Recommended Dietary Allowances (RDAs) or calcium and vitamin D, speciying the amounts that meet the basic health needs o 97% o all people at a given age. Te RDAs or calcium and vitamin D appear in able 1 (see above).
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Calcium supplements: Harmful to the heart? or several years, evidence has suggested that people who consume the highest levels of calcium from supplements may be more likely to have heart disease and heart attacks, or to die from heart problems. In contrast, none of the studies has found that calcium in
F
to calcium supplements may be a coincidence. But there is at least a hypothetical connection. Over time, calcium does tend to accumulate in arteries that are damaged by high blood pressure and the buildup of fatty plaque deposits. As a result, the arteries become stiffer and
food—milk, cheese, leafy greens, and a range of vitamin- and mineral-fortified grocery products—is associated with greater risk.
narrower.. If a plaque bursts open, it can narrower trigger a heart attack, stroke, or sudden cardiac arrest.
These studies do not provide conclusive proof that calcium supplementation causes cardiac problems, however. however. People develop cardiovascular disease for various reasons, and the connection
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For someone who is already losing bone or at risk of bone fractures, however, however, the benefits of calcium may outweigh any hypothetical risk of heart disease. Talk with your doctor doct or about what’s right for you.
Controversy over the IOM recommendations
you would need to take quite a large amount o it
Tese recommendations wereexperts not metthink with that universal approval, however. Some the IOM’s recommendations underestimate the amount o vitamin D that people ages 51 and older should take to prevent bone loss and lower the chance o harmul ractures. Te National Osteoporosis Foundation, or example, concurs with the IOM on calcium, but boosts the recommendation or vitamin D to 800– 1,000 IU daily or men and women in this age group. Some vitamin D researchers recommend even higher levels. But the U.S. Preventive Services ask Force reviewed the existing studies and ound no evidence
to get into the upper dangerlimit zone. to4,000 the IOM report, the sae orAccording vitamin D is IU. IU. So what should you do? Here is a reasonable approach: Get as much calcium and vitamin D as you can rom ood (up to the recommended amounts), and make up any shortall with a daily supplement. You can also get vitamin D rom sun exposure, at least during the summer (see “Sources o vitamin D,” page 26). I you are in your 50s or older, aim or 1,200 mg o calcium and 800 to 1,000 IU o vitamin D per day. And ask your doctor or advice i you are conused about mixed messages rom the media.
that more than 400 IU o vitamin D a day was helpul or preventing ractures. Te task orce does not deny that higher levels could be beneficial—it only states that the current evidence is insufficient to prove it. Why be so picky? Why not just take more than enough vitamin D, as a sort o insurance policy? One reason not to overconsume any vitamin or mineral supplement is that it requires time, effort, and money. Ideally, you want to take what you need and no more. More important, taking too much o certain nutrients can be harmul (see “Calcium supplements: Harmul to the heart?” above). Te IOM report set the sae upper limit or calcium intake at 2,000 mg daily. Excessive vitamin D could also be harmul, although
Calcium in your diet Most experts would agree that getting calcium rom a balanced, nutritious diet is preerable to taking supplements. Foods typically don’t have the side effects o calcium supplements, like constipation and a small but worrisome increase in cardiovascular risk. Moreover Moreover,, calcium-rich ruits, vegetables, nuts, and legumes contain many other healthy nutrients that can help protect you against heart disease. Luckily, i you want to increase your dietary calcium intake, you have plenty o oods rom which to choose. able 2 (see page 23) shows how much calcium is ound in a number o common grocery items. You
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may be surprised at how much calcium you can add to your diet by making a ew simple substitutions, such as choosing ricotta instead o cottage cheese, or opting or ortified orange juice over regular. Many osteoporosis experts avor dairy products Table 2:
as a source o calcium. Dairy provides the most concentrated sources. Moreover, milk is ofen ortified with vitamin D. And the many reduced-at milks, yogurts, and cheeses available today make it possible to cut at and calories without skimping on calcium.
Calcium-containing foods
FOOD
CALCIUM (mg)
Cheeses (1 oz., unless otherwise noted)
FOOD
CALCIUM (mg)
Ve Vegetables getables (1 cup, boiled, unless otherwise noted)
ricotta, part skim (½ cup)
334
spinach
245
Swiss
224
kale
94
p r ov ol on e
214
broccoli
62
mozzarella, part skim
207
parsnips
58
cheddar
204
Brussels sprouts
56
mozzarella, regular
143
artichoke (1 medium)
54
feta
140
summer squash
49
cottage cheese, 1% fat (½ cup)
69
cabbage
47
Frozen desserts (½ cup)
Fruits and fruit juices (1 cup, fresh, unless otherwise noted)
ice cream, light, vanilla
106
rhubarb, frozen, cooked
348
ice cream, regular, vanilla
84
orange juice, calcium-fortified
300
blackberries
42
Milk (1 cup)
sk i m
306
orange juice, regular
27
1% fat
290
strawberries
27
2% fat
285
kiwi (1 medium)
26
whole
276
apricots, dried (10 halves)
19
raisins, dried (¼ cup)
18
Yogurt Yogu rt (8 oz.)
flavored, low-fat
345
plain, whole-milk
275
Nuts and seeds (1 oz., unless otherwise noted)
Fish (3 oz.)
sardines, Atlantic, canned in oil, including bones
325
salmon, pink, canned, including bones
181
almonds, unblanched
70
ocean perch, Atlantic
116
sesame paste, tahini (1 tablespoon)
64
bass, freshwater
68
hazelnuts
32
trout, rainbow
73
sunflower seeds
20
halibut, Atlantic or Pacific
51
peanuts, oil-roasted
17
anchovies, canned in oil, drained (5)
46
Legume products (½ cup)
Shellfish (3 oz.)
tofu, firm, made with calcium sulfate (¼ block)
163
crab, blue
88
soybeans, green, boiled
130
lobster, boiled
52
navy beans baked beans, canned, with franks
63 62
crab, Alaska king shrimp
50 50
Adapted, with permission, from the U.S. U.S. Department of Agriculture, Composition of Foods; Ohio State University Hospital, Nutrient Database Catalog. w w w . h e a l t h . h a r v a r d . e d u
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In act, these products ofen contain slightly more calcium than their high-at counterparts do. Tere is, however, one potential concern about dairy that has not yet been resolved. Some research suggests that men who consume a large amount o dairy products may be at greater risk or prostate cancer. Because the men in these studies also ate ewer ruits and vegetables, it’s difficult to tease out which actor—more milk or less produce—contributed to the risk. More research is needed to determine whether the bone benefits o dairy are worth the possible associated risks in certain men. Many people avoid dairy or other reasons—most prominently, lactose intolerance. I you’re lactose intolerant and have trouble digesting dairy products, try taking the enzyme lactase—either as a pill or in liquid orm—to help you enjoy these oods without worrying about unpleasant side effects. You can even find some dairy products that already have lactase added. Or switch to soy or almond milk, which also
Spread it out Your body has a hard time absorbing large amounts of calcium all at once. So it’s best to get your calcium in doses of 500 mg or less, a few times throughout the day. To get the most out of calcium-rich foods and supplements, don’t take your supplement with a glass of milk. Instead, take your supplement a few hours after drinking your milk or calciumfortified orange juice; that gives your body a chance to draw as much calcium from these sources as possible.
o determine how many milligr milligrams ams o calcium per serving a product contains, multiply the percentage figure in the Nutrition Facts box by 10. For example, i a product’s ood label says that one serving provides 20% o your daily calcium requirement, that means it contains 200 mg o calcium. (Tis works or calcium because the Daily Value is 1,000 mg, but it will not work or other nutrients listed on the label.) Also
what constitutes a serving. haveDairy calcium added.are not the only sources o calcium know same amount you normally eat. It may be not be the products in the diet. Te plant kingdom is also calcium-rich, with spinach, dried beans, and nuts among the best Calcium supplements sources. Teir calcium content can can’t ’t always be accepted While experts recommend getting your nutrients rom at ace value, however. For example, the oxalic acid in oods instead o supplements, you may find that it just isn’t ’t practical or possible or you to get all the calcium spinach and rhubarb binds the calcium in these plants isn so that the calcium isn’t readily absorbed. Insoluble you need rom your diet. In that case, a supplement fiber, such as that in wheat bran, also reduces calcium can shore up your calcium intake and your bones. In absorption. (Soluble fiber, such as the pectin in ruit, act, one analysis o several studies o postmenopausal does not.) Unortunately, there is no easy equation or women ound that the women who took calcium and determining how much o the calcium content o a vitamin D supplem supplements ents or or aatt least two yea years rs wer weree 23% ruit or vegetable is actually absorbed. less likely to suffer a spinal racture. Fortified oods are another option. Just a cup A dizzying array o calcium supplements are o ortified orange juice supplies about 300 mg o available, including pills, chewable tablets, flavored calcium, and three-quarters o a cup o some ortified chews, and liquids (see able able 3, page 25). When making cereals, such as Whole Grain otal, offers 1,000 mg. a decision, it’s wise to consider cost, convenience, and Food labels, while helpul, oten require how well your body tolerates the supplement. translating. Te label inormation helps you deterhe calcium in supplements is ound in mine how much calcium is in the preparation, not combination with another substance, typically how much you need. Packaged oods list calcium carbonate or citrate—though, less commonly, you content as a percentage o the FDA’s Daily Value, find products that combine calcium with phospha phosphate, te, which is 1,000 mg or adults. However, i you are a lactate, or gluconate. woman age 51 or older, the IOM recommends 1,200 Calcium carbonate. Tis tends to be the best mg o calcium a day—not 1,000—so the percentages value, because it contains the highest amount o eleon the label will not be accurate or you. mental calcium—the actual amount o calcium in 24 Osteoporosis
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Table 3: Common calcium supplements AMOUN T OF ELEMENTAL (ACTUAL) CALCIUM
SERVING SIZE (number of pills you must take to get the amount of calcium listed at left)
COST PER SERVING*
BRAND
TYPE OF CALCIUM COMPOUND
Caltrate 600+D Calcium Supplement
Calcium carbonate
600 mg
1 tablet
12–13 cents
Caltrate 600+D3 Plus Minerals Chewables
Calcium carbonate
600 mg
1 chewable tablet
12–13 cents
Citracal Calcium + D3 Petites
Calcium citrate
400 mg
2 caplets
14 cents
Citracal Plus Magnesium
Calcium citrate
500 mg
2 tablets
11 cents
GNC Calcimate Plus 800 with Magnesium and Vitamin D3
Calcium citrate malate
800 mg
4 tablets
24–33 cents
GNC Calcium 1,000 with Magnesium and Vitamin D3
Calcium carbonate
1,000 mg
3 tablets
16–21 cents
GNC Calcium Citrate 1,000
Calcium citrate
1,000 mg
4 tablets
21–28 cents
Os-Cal Calcium with Vitamin D3
Calcium carbonate
500 mg
1 tablet
8–10 cents
Os-Cal Ultra 600 Plus Caplets
Calcium carbonate
600 mg
1 caplet
12–13 cents
Tums (regular (regular strength) strength)
Calcium carbonate carbonate
400 mg
2–4 chewa chewable ble tablet tabletss
8–10 cents
Tums E-X Extra Strength Antacid/Calcium Supplement
Calcium carbonate
600 mg
2 chewable tablets
11 cents
Tums Ultra
Calcium carbonate
800 mg
2 chewable tablets
12–15 cents
Viactiv Calcium Chews Plus Vitamin D and K Supplement for Women
Calcium carbonate
500 mg
1 flavored chew
14 cents
*Based on a random sampling. Prices may vary.
each supplement. Te compound calcium carbonate contains 40% calcium by weight, while calcium citrate is 21% calcium. Because calcium carbonate requires
In weighing your options, check the labels o products to see what the serving size is and what the “% Daily Value” or calcium is. Ten multiply the
stomach acid or absorption, it’s best to take this product with ood. Most people tolerate calcium carbonate well. However, some people complain o mild constipation or eeling bloated. Some well-known calcium carbonate products include Caltrate, Viactiv Calcium Chews, Os-Cal, and ums. Calcium citrate. Tese products are absorbed more easily than calcium carbonate. Tey can be taken on an empty stomach and are more readily absorbed by people who are taking an acid-reducing heartburn medication. But because calcium citrate is only 21% calcium, you may need to take more tablets to get your daily requirement. Calcium citrate products include Citracal and GNC Calcimate Plus 800.
percentage by 10 to find out how much elemental calcium the product contains. For example, i the label says a serving o the product con contains tains 40% o the Daily Value, it has 400 mg o elemental calcium. Reading the labels with an eye toward cost and convenience may help you sif through your options. Would you find it inconvenient to take several tablets a day? How many tablets or chews does the package contain, and what is your cost per serving? While products that yield a high amount o calcium may seem to be the best bet at first blush, they may not serve you best. Because your body has difficulty absorbing more than 500 mg o calcium at a time, more o the mineral may go to waste (see “Spread it out,” page 24). So while
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Experts generally recommend getting your nutrients from food rather than supplements. There There are many foods that contain calcium and a few, such as eggs, that contain vitamin D.
calcium our hours beore and afer taking levothy roxine, because calcium can c an interere with this d drug’ rug’ss absorption. Ask your doctor or pharmacist whether a supplement will interact with any other prescription medications you’re taking. • Don’t exceed the daily dose recommended by the manuacturer, since doing so increases the risk or side effects. • Vitamin D helps your body absorb calcium, but it’s not necessary to take them at the same time. However, i you aren’t getting enough vitamin D rom sunlight, your diet, or your multivitamin, you may want to choose a calcium supplement that contains the vitamin.
you may think that you’ve met your daily requirements by taking that 1,000-mg calcium pill, you may actually be only halway to your target.
Sources of vitamin D Vitamin D is called “the sunshine vitamin,” and or good reason. Your skin cells use sunlight to produce a precursor chemical that the liver and kidneys then
Here are ew other thingssuppleme to keep innt:mind when choosing andataking a calcium supplement: • Generally, calcium pills are better choices than multi vitamins, which tend to have small amounts o elemental calcium. • Te National Osteoporosis Foundation recommends avoiding calcium products made rom unrefined oyster shell, bone meal, or dolomite that don’t say “purified” or have the United States Pharmacopeia (USP) symbol on them, since these products have tended to contain higher levels o lead, a toxic metal. • Also avoid coral calcium, a supplement made rom
convert into D active Someoutside peopleor make all the vitamin theyvitamin need byD.going a ew minutes a day with bare arms and legs. (Don’t wear sunscreen during this short time, except on your ace to avoid the photoaging effects o the sun.) Keep your exposure time short—just 10 minutes or so a day— to guard against skin cancer. And i you’re out longer than that, do cover up or apply sunscreen. However, it’s unlikely that sunlight alone will generate adequate amounts o vitamin D or most Americans during much o the year. For example, i you live above 40 degrees latitude (the latitude o
Japanese coral. Coral calcium supplements have also been ound to contain lead, along with mercury and cadmium—a metal that has been linked to cancer as well as kidney and lung diseases. And although man man-uacturers have asserted that the body absorbs more calcium rom coral calcium than rom other supplements, no evidence exists to back up this claim. • Because calcium, iron, and zinc supplements interinterere with each other other,, take them several hours apart. • Similarly, delay consuming calcium (either rom ood or supplements) or two to our hours afer taking tetracycline antibiotics, since calcium can decrease the drugs’ effectiveness. People with hypothyroidism (underactive thyroid) should avoid
Denver, Indianapolis, and Philadelphia), the winter sunlight isn’t strong enough to enable you to produce
26 Osteoporosis
Table 4: Recommended daily vitamin D intake in adults The National Osteoporosis Foundation recommends a higher daily intake of Vitamin D than the Institute of Medicine does. doe s. (F (For or the IOM recommendations, see Table 1, page 21.) SE X /AGE
V ITAMIN D
Men and women under 50
400–800 IU
Men aannd w woomen 50 50 an and oollder
800–1,000 IIU U
Source: National O Osteoporosis steoporosis Foundation.
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significant amounts o vitamin D. Sunscreen, glass, and clothing also interere with this process, diminishing your ability to produce the vitamin. People with dark skin produce less vitamin D than those with air skin. And no matter who you are, as you age, your skin can’t produce vitamin D as readily, and your intestines have more difficulty absorbing this vitamin rom ood or supplements. For this reason, many vitamin D experts would recommend that you not only ollow the National Osteoporosis Foundation’s recommendations or vitamin D intake (see able 4, page 26), but also have your blood tested or vitamin D to gauge how much is actually getting into your system. Te National Institutes o Health defines a normal blood level o vitamin D as 30 to 74 nanograms nanograms per milliliter milliliter.. Vitamin D in your diet You can try to make up or the shortall with your
diet, but only a ew oods—such as eggs, fish, and liver—naturally contain vitamin Dsaltwater (see able 5, at right). Mushrooms have vitamin D i they’ve been exposed to sunlight, but don’t assume they contain it unless the packaging says so. In the United States, milk is ortified with this vitamin; an 8-ounce glass should h have ave about 100 IU or more. In addition, the FDA has approved the use o a particular type o yeast that can quadruple vitamin D levels in bread. A slice o bread should have roughly 100 IU or more, i it’s labeled “rich in” or “an excellent source o” vitamin D. Vitamin D supplements Given the difficulties o obtaining adequate vitamin D rom the sun and ood, most people find they need to supplement. Vitamin D3, or cholecalcierol, is the orm most easily absorbed and used by the body, so choose a product with D3 i possible. Most multivitamins contain 400, 1,000, or 2,000 IU o vitamin D, but 1,000 IU is the most popular dosage. Check the amount o vitamin D careully. I it’s low, you may need to add an additional source, such as a vitamin D capsule or a teaspoon o cod-liver oil. Just don’t overdo it. A 2015 study sponsored by the National Institutes o Health ound that women w w w . h e a l t h . h a r v a r d . e d u
Table 5: Foods containing vitamin D FOOD
S ER V I NG
V ITA MIN D (IU )
Sockeye salmon, cooked
3 ounces
447
Tuna fish, canned in water, drained
3 ounces
154
Orange juice,
1 c up
137 (amounts vary
fortified with vitamin D Whole milk, fortified
1 c up
by product) 124
Ready-to-eat breakfast cereal
1 cup (without milk)
100
Yogurt, fortified
6 ounces
80 (check the label, because many brands are not fortified)
Sardines, canned in oil
2 sardines
46
Beef liver, cooked
3 ounces
42
Egg
1 large
41
Source: National National Institutes of Health, Ofce of Dietary Supp Supplements. lements.
who took ultra-high-dose vitamin D supplements (50,000 IU daily or 15 days, ollowed by 50,000 IU every 15 days or a year) had no difference in bone density o the spine, total hip, emoral neck, or total body compared with women who took low-dose supplements suppleme nts or a dummy pill. Although their calcium absorption increased, the increase was slight. It’s not wise to double up on your multivitamins either, since that will deliver unhealthy amounts o other nutrients, such as vitamin A, which can actually lower bone density (see “Potential dietary dangers,” page 28).
Vitamin K You know that calcium and vitamin D are good or your bones, but did you know that the vitamin K in leay greens may also help keep them strong? Vitamin K helps your body produce osteocalcin, a protein that is instrumental in bone b one ormation. It also blocks substances that break down bone and helps regulate calcium excretion rom the body in urine. Furthermore, research has shown that people deficient in vitamin K tend to have lower bone strength and are more prone to ractures. Osteoporosis
27
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Vitamin K in your diet Current recommendations call or 120 mcg o vitamin K per day or men and 90 mcg or women. Most diets easily supply this amount. For example, a cup
stances they take in. Afer all, it’s easier to preserve bone than to rebuild it once it’s lost. Caffeine. Some preliminary research suggests that drinking our or more cups o coffee a day can put you at greater risk o breaking a bone. It seems that taking in high levels o caffeine increases calcium excretion by the kidneys. More study is needed, but in the meantime you may want to orgo that ourth cup. Salt. In addition to raising blood pressure, too much sodium in your diet can increase the amount o calcium your body excretes in urine. Following nutritional guidelines by consuming no more than 2,300 mg daily can help prevent this effect. So can eating oods high in potassium, such as bananas, avocados, and leay green vegetables. Protein. Some experts believe that high levels o protein, particularly protein rom animal sources, may raise the acidity o the body, causing calcium to leach rom your bones in order to neutralize the acidity.
o meet resh the rawdaily spinach will deliver than enough to requirement, andmore so will a generous portion o cooked broccoli or Brussels sprouts. Other good sources o vitamin K include collard greens and other green leay vegetables. I you don’t like those vegetables, try scallions, asparagus, or cabbage. C Cerertain herbs, such as basil, sage, and thyme, also have significant amounts o vitamin K. Some people have to be careul with vitamin K, however. I you take anticoagulants like wararin (Coumadin), it’s particularly important to keep your vitamin K intake consistent rom day to day day,, since
Tis issue is is no consensus onstill howbeing muchinvestigated, protein mayand be there harmul to bones—i there is such a threshold at all. Alcoh ol. Heavy drinking seems to sap calcium Alcohol. rom bones and interere with production o vitamin D (see “Excess alcohol consumption,” page 11). Soda. Sot drinks—both ull-sugar and diet ones—affect the body’s calcium stores because the phosphate in soda intereres with the absorption o calcium rom oods. I the soda is caffeinated, that compounds the trouble, as the caffeine increases the amount o calcium removed.
this vitamin influences blood clotting. I you take an anticoagulant, ask your doctor i it’s sae or you to take vitamin K.
Vitamin Vit amin A. Several studies have ound a link
For example, in a systematic review o 13 studies in Annals of Internal Medicine, most o the studies showed that taking vitamin K increased b bone one density density.. Seven trials ound reduced racture risk, all involving Japanese people taking the orm o vitamin K called menaquinone (vitamin K2). Menaquinone is a popular osteoporosis treatment in Japan. Tat’s not the only evidence. In the Nurses’ Health Study, women who got at least 100 micrograms (mcg) o vitamin K a day were 30% less likely to break a hip than women who got less. Similarly, in the Framingham Heart Study, people who got the most vitamin K were less likely to break a hip than those who got the least.
Potential dietary dangers Researchers have identified some components o a typical American diet that may compromise bone health. In some cases, the science is not absolutely clear on how much o these oods are harmul. However,, the evidence is strong enough that anyone who is ever at risk o low bone density—postmeno density—postmenopausal pausal women, or example—might consider how much o these sub-
28 Osteoporosis
between high vitamin A intake and ractures. Currently, the recommended daily amount o vitamin A is 700 mcg (about 2,300 IU) or women and 900 mcg (about 3,000 IU) or men. You can get vitamin A as preormed vitamin A or as its precursor, the nutrient beta carotene (which the body converts into vitamin A). Beta carotene has not been linked to ractures and is thereore a saer way to ulfill your vitamin A requirements. I you take a multivitamin, check to make sure that a significant part o its vitamin A comes rom beta carotene. Also, avoid taking highpotency vitamin A supplements.
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Protecting your bones: Exercise xercise plays a dual role in fighting the effects o osteoporosis. First, it can help preserve the bone strength you still have. Second, it improves coordination and balance, which can prevent the alls that could lead to ractures. A study by Harvard researchers ound that women who walked more than our hours per week had a significantly lower risk o hip ractures than women who walked less than an hour per week. While exercise, like diet, can’t rebuild bone to the extent that medicine can, it might mig ht contribute to small increases in bone density density.. However, bone health is not the only reason to work out. Regular exercise also lessens your chances
E
your doctor about the types o activity that are right or you. (Note that while swimming and bicycling are excellent ways to keep fit, they aren’t weight-bearing, so they won’t improve your bone mass or density.) Tere are a couple o rules o thumb to be aware o i you’re aiming or maximum effect on bone and you are able to work out vigorously. Generally, higherimpact activities have a more pronounced effect on bone than lower-impact exercises; sports such as tennis, volleyball, or running build bone aster than walking or low-impact aerobics. Velocity is also a actor; jogging or ast-paced aerobics will do more to strengthen bone than more leisurely movement. And
o getting heart disease, pressure, helps prevent diabetes, reduceslowers the riskblood or colon and breast cancer, improves mood, and adds years to your lie. I these health benefits came in a pill, people would be clamoring or a prescription.
keep mind that thoseFor bones that bear the load o theinexercise willonly benefit. example, walking or running protects only the bones in your lower body, including the hip. By contrast, a well-rounded strength training program that works out all the major muscle groups can benefit practically all o your bones. And strength training is the only type o exercise that targets the very sites most likely to sustain ractures rom osteoporosis—bones osteoporosis—bo nes o tthe he hip, spine, and arms. (See the Special Section, “Strength training and balance exercises or bone health,” page 34, or workout ideas,
How weight-bearing exercise benefits bones Weight-bearing exercise can significantly increase bone density during childhood and adolescence. Te effects aren’t as dramatic in adulthood. But weight-
bearing exercise is helpul then, too, because move- particularly i you’re you’re new to strength ttraining.) raining.) o keep your bones healthy, aim to get at least 30 ment that compels you to work against gravity stresses your bones enough that your body responds by rein- minutes o general weight-bearing exercise a day— reserving classic strength training with weights or orcing the bones that are under duress. What exactly is weight-bearing exercise? It’s not just two to three days a week, with at least 48 hours just classic strength training (also known as weight between sessions. It’s important to exercise regularly; training or resistance training), where you work out inrequent activity won’t strengthen your bones. In addition to helping maintain bone density, with weights in the gym. Weight-bearing exercise includes any exercise where your body is bearing exercise helps protect against ractures in other ways. your weight. Tat could include vigorous sports, Strength training increases muscle mass, which in such as tennis or running, which are options i you’re turn enhances muscle control, strength, balance, and trying to prevent osteoporosis. I you already have coordination. Good balance and coordination can the condition, start with a gentler orm o weight- mean the difference between alling—and suffering bearing exercise, such as walking or tai chi. alk with a racture—and staying on your eet. Strong evidence w w w . h e a l t h . h a r v a r d . e d u
Osteoporosis
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Beyond bones: Putting together a total fitness routine for overall health Exercise delivers powerful, wide-ranging health benefits, but to reap its full rewards you must perform several different types of activities on a regular basis. Here are the various elements of a well-rounded program. Aerobic. Each week, accumulate at least 150 minutes of moderate activity or 75 minutes of vigorous activity, or an equivalent mix of the two. Sustain activities for at least 10 minutes at a time. Strength. Do strength exercises for all major muscle groups (legs, hips, back, chest, abdominals, shoulders, arms) at least twice weekly. Repeat each exercise eight to 12 times per set, aiming for two to three sets. Rest muscles for at least 48 hours between strength training sessions. Balance. For older adults at risk for falls and others concerned about osteoporosis, include activities that enhance balance, such as tai chi or yoga, at least twice a week. Flexibility. Do stretching or other flexibility exercises, preferably on days when you do aerobic or strength activities, or at least twice a week. Hold stretches for 10 to 30 seconds,
d t L a i d e m k a e r b e v a W ©
A sedentary lifestyle is one of the major risk factors for heart disease. Regular physical activity—such as walking, gardening, or golfing—can reduce your risks.
repeating each stretch three to four times.
shows that regular physical activity can reduce alls by nearly a third in older adults at higher risk o alling.
Although there are many types o weight-bearing exercise, classic strength training can deliver the most benefits to the maximum number o bones. A strength
Groups o eight to 12 reps make up one set. Tough perorming one set is effective, two to three sets may be better. Give yoursel a minute or more to rest between sets. No matter what routine you use, the ollowing tips or sae and effective strength training will help you get the most rom your workouts. Warm up and cool down for five to 10 minutes.
training program typically employs equipment such as weight machines, ree weights, and resistance bands or tubing. Not only does strength training protect against bone loss, but it also builds muscle and improves your body’s ratio o lean muscle mass to at. As a result, it deserves an important place in your exercise routine routine.. Te Physical Activity Guidelines or Americans, issued by the U.S. Department o Health and Human Services, recommend strengthening exercises or all major muscle groups (legs, hips, back, chest, abdominals, shoulders, and arms) two or three times
Warming up brings nutrient-rich, oxygenated blood to your muscles while raising your heart rate and breathing. Cooling down slows breathing and heart rate to help prevent a sudden drop in blood pressure that can cause dizziness. End with stretches. Focus on form, not weight. Align your body correctly and move smoothly through each exercise. Poor orm can prompt injuries and delay gains. Many experts suggest starting with no weight, or very light weight, when learning a strength training routine. Concentrate on slow, smooth lifs and equally con-
per week. Generally eachmight exercise is done multiple times—or example, you do eight biceps curls in a row. Tese are known as repetitions, or “reps.”
trolled descentsand while isolating muscle muscles group—that is, contracting releasing theaspecific that you want to strengthen.
Classic strength training
30 Osteoporosis
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Maintain a steady tempo. empo—or example,
counting to three while lowering a dumbbell, then counting to three while raising it again—helps you stay in control. oo much speed and momentum can undercut strength gains and undermine orm. Breathe. Blood pressure rises i you hold your breath while perorming strength exercises. Exhale as you lif, push, or pull a weight; inhale as you release. Keep challenging your muscles. Begin with a weight that you can comortably lif or eight to 12 repetitions. Te right weight differs depending on the exercise. Choose a weight that tires the targeted muscle or muscles by the last two reps while still allowing you to maintain good orm. I you can’t do the last two reps, choose a lighter weight. When the complete set eels too easy, challenge your muscles again by adding weight (roughly 1 to 2 pounds or arms, 2 to 5 pounds or legs) or adding another set o reps to your workout (up to three sets). I you add weight, remember that you be able to do all the reps and should the targeted muscles should eel with tired good by theorm last two reps. Most sporting goods stores sell dumbbells with adjustable weights, as well as wrist and ankle bands that asten with Velcro and have pockets or weights. Look or sets that allow you to add weights in hal- to 1-pound 1-p ound increments. Practice regularly. W Working orking all the major muscles o your body two or three times a week is ideal. You can choose to do one ull-body strength workout two or three times a week, or you may opt to break your strength workout into upper- and lower-body components. In that case, be sure that you perorm each o these components two or three times a week. Give your muscles time off. Strenuous exercise like strength training causes tiny tears in muscle tissue. Muscles grow stronger as the tears t ears knit up. Always allow at least 48 hours between sessions or muscles to recover. So, i you do a ull-body strength workout on Monday, wait until at least Wednesday to repeat it. I you’re doing a split strength session, however, you might do upper-body exercises on Monday, lowerbody exercises on uesday, upper-body exercises on Wednesday, exercises Tursday, etc. Keep it lower-body up. As with other on orms o exercise, consistency is the key to getting good results rom w w w . h e a l t h . h a r v a r d . e d u
Vibrating platforms: Do they help those who are unable to exercise?
A
therapy called whole body vibration is being promoted as a way to prevent bone loss in those who are too frail or too incapacitated to exercise. The idea is that by standing on a vibrating platform, a person experiences barely perceptible vibrations vibrations that travel up through the soles of the feet. These vibrations cause muscle cells to react as they would to common activities such as standing, keeping balance, and walking. They twitch in sequence, making tiny contractions that exert small stresses on bones, resulting in increased bone density and muscle mass. But the platforms can be expensive, and the evidence is mixed that this therapy actually strengthens bones and prevents osteoporosis. In one study, postmenopausal women were asked to stand on a vibrating platform for 20 minutes a day on either the high or low speed; these women were compared with a group who did not use the device. After a year, year, there was no difference in bone loss between the two treated groups and the untreated group. A 2015 review of studies on vibrating platforms for postmenopausal osteoporosis concluded that more research is needed to determine the mechanisms behind this therapy’s potential effects on bone. And while the authors say vibrating platforms might provide some benefits when used as an add-on therapy, therapy, they are no substitute for standard treatments like bone-building medications and a bone-healthy diet.
strength training. As little as our to six months o regular weight training can help you maintain—or even improve—bone density. But people who stick with it or a year or more achieve the greatest gains. I you stop working out, any increases in bone and muscle strength will disappear within five years.
Safety first A well-designed fitness program can improve your strength and mobility, but a poorly executed plan could actually lead to a racture. With weak bones, it’s imperative that you exercise saely. Here are some general guidelines to help anyone with osteopenia or osteoporosiss make a smooth ttransition osteoporosi ransition to a new workout routine: the exercises by your doctor first to make • Run sure they’re safe for you to try. Getting your docOsteoporosis
31
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tor’s okay is especially important i you’ve ractured a bone in the past p ast or i you have an additional condition, such as diabetes or heart disease. • Book a few sessions with a physical therapist. Go through each exercise, step by step, having the therapist check your orm. Keep going back to the therapist until you’re completely comortable doing the exercises on your own. • Pace yourself. No effective exercise program was created in a day. Start slowly, giving yoursel time to adjust to the pace and movements. Gradually increase both the length and intensity o your workouts as you eel ready.
• Avoid risky movements. Don’t lif heavy weights. And stay away rom any exercise that could end in a all—or example, an unbalanced yoga pose or standing on a chair. • Avoid spinal bends and twists. Be careul not to make any quick reaching or twisting motions, especially i you’ve broken a bone. You may need to modiy certain exercises to make them sae or avoid them altogether. For example, to protect your vertebrae, orgo exercises and machines that put added stress on the spine, such as leg press machines, leg raises perormed lying down, and squats done with weight bars resting on the shoulders. Gol swings
Tai chi improves improv es balance, muscle strength, and flexibility
E
vidence is growing that tai chi, a mind-body practice that originated in China as a martial art, has value in treating or preventing many health problems. TTai ai chi helps improve balance, and there is preliminary evidence that it may help maintain bone strength, too. In this low-impact exercise program, you move without pausing through a series of slow motions. Throughout these gentle movements, the muscles are relaxed rather than tensed, the joints are not fully extended or bent, and connective tissues are not stretched. Because you are standing and you shift your body weight leg to leg, you getfrom the benefit of weight-bearing exercise, which may account for the potential bone-strengthening effect—though the impact is much lower and thus the effect on bone is less than with more vigorous exercise. On the other hand, tai chi is slow and gentle enough to be easily adapted for anyone, from the fittest individuals to people confined to wheelchairs or recovering from surgery. surgery. Especially important is that it is safe for people who are elderly, elderly, frail, and out of condition—individuals at particularly high risk for falls and broken bones.
32 Osteoporosis
Although the research on tai chi for bone strength has yielded mixed results, one study in Taiwan found that longtime practitioners of tai chi had greater bone density at the hip and spine compared with people who didn’t do tai chi. Another Another study found that bone density actually increased in the hip and spine in people who practiced tai chi for 10 months. By contrast, those who didn’t practice tai chi saw declines in bone density over the same period. A third study found benefits equivalent to 12 months of resistance training. In addition to its effects on bones, tai chi improves muscle strength, flexibility, and balance—all of which help you stay fit and avoid falls and fractures. It can also slightly improve aerobic conditioning, if it is done at a fairly rapid pace and is challenging enough. eno ugh. What’s What’s more, tai chi doesn’t require any special equipment or
facilities. Here is more detail on tai chi’s benefits: Muscle strength. Even without the assistance of weights or resistance bands, tai chi can help build muscle strength in the lower and upper extremities as well as the core muscles of the back and abdomen. Flexibility. Ta Taii chi significantly boosts upper- and lower-body flexibility. Balance. Not only does tai chi help keep you from losing your balance in the first place. If you do stumble, the muscle strength and flexibility you gain from tai chi can help you recover before a stumble turns into a fall. Proprioception. Proprioception is the ability to sense the position of one’s body in space, and it declines with age. Tai chi helps train this sense, which is a function of sensory neurons in the inner ear and stretch receptors in the muscles and ligaments. conditioning. Depending on Aerobic conditioning. Depending the speed and size of the movements, tai chi can provide some aerobic benefits. But to meet government fitness guidelines and get full cardiovascular and other health benefits, you’re better off relying on standard aerobic activities, such as brisk walking.
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and sit-ups also place stress on the spine and may result in vertebral ractures. • Don’t overdo it. Expect to be sore during your early exercise sessions, but i you’re in pain, ease back. You might be moving too quickly or pushing yoursel too hard.
Preventing falls
In essence, the treatment and prevention o osteoporosis is aimed at a single goal: to orestall the ractures ractures that can threaten independence, steal mobility, trigger depression, and result in pain, disability, or even death. You can do that either by building bone or by preventing the alls that ofen lead to ractures—or better yet, by doing both. Falling is one o the biggest causes o ractures, particularly among older people. More than 95% o hip ractures result rom a spill. Tereore, researchers, doctors, and osteoporosis-pre vention organizations organizations ocus ocus quite a b bit it on this sub subject. ject. All people are more susceptible to alls as they age, but women are even more likely than men to all. You can help reduce the threat o alls by practicing exercises that improve your balance. (For specific examples, see “Balance exercises,” page 38.) I you are already doing some strength training, you may find that many o your current exercises are helpul or improving balance as well, because they strengthen muscles that you use to maintain balance. In addition to balance exercises, power exercises (strength exercises that emphasize speed) can help
Can yoga help prevent osteoporosis? Could regularly performing a series of poses help preserve bone strength? A 2016 study in the journal Topics in Geriatric Rehabilitation suggests that a daily yoga practice might do just that. The study included 741 people, who were an average of 68 years old when they started. Most had lower-than-normal bone density density.. After participating in a daily 12-minute yoga routine over a period of 10 years, the participants underwent DEXA scans, which revealed gains in bone density in their spines, hips, hips, and femurs. While promising, the study applies to people with osteopenia, not osteoporosis. Many of the yoga poses used in this study involved spinal twists, side bends, and back extensions that help with prevention, because they place stress on the muscles around the spine. However, people who already have osteoporosis should avoid exercises that involve flexing the spine because they can further damage vertebrae that are already weakened by osteoporosis. Yoga does have undeniable health benefits, including improved balance and coordination that could prevent falls. If you are interested in trying yoga, check with your doctor or ayou physical first,know to make sure it’s appropriate for and totherapist be sure you what poses are safe for your level of bone strength.
10 more ways to prevent falls Exercise is not the only thing you should do to pre vent alls. Falls can result result rom a host o actors, some health-related and some environmental, such as ail-
house that can help minimize your risk o alling: 1. Clear your floors o clutter and any items that could trip you up, including loose wires, cords, and throw rugs. 2. Make sure that stairways, entrances, and walkways are well lit, and install night lights in your bedroom and bathroom. 3. Clean up spills immediately. 4. Wear rubber-soled shoes or better traction. Avoid walking around in socks. 5. Limit your intake o alcohol. 6. Keep items that you use ofen in easy-to-reach cabinets. Also, consider using reaching and grasping tools to get at difficult-to-reach di fficult-to-reach items. 7. Add grab bars to your tub, and use nonskid mats on bathroom floors. 8. Be careul when pets are nearby. ripping over a pet, most ofen a dog or cat, c at, is a common cause o alls.
ing vision or dizziness (sometimes caused by medication medications), s),hearing, bad lighting, wet floors, and obstacles in pathways. Here are some simple changes around the
alkare to your about whetherorany medications 9. you takingdoctor can cause dizziness impair balance. 10. Have your eyes checked regularly.
reduce alls by improving your reaction time i you start to trip or lose your balance. Tere are our power exercises in the workout o the Special Section. Tey’re listed as variations under the standing cal raise (see page 35), stair climbing (page 35), triceps dip (page 36), and chair stand (page 36).
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SPECIAL SECTION
Strength training and balance exercises for bone health “
W
hat type of exercise program should I follow?” Tis is one of the most common questions doctors hear from patients who have concerns about thinning bones. Tey are aware that exercise can play a role in slowing bone loss, but they don’t know what type
of exercise is best. Te short answer is weight-bearing exercise. But what does that mean? As discussed in the previous chapter, it’s not just lifing weights, but rather any exercise in which your body is bearing your weight. (See “Protecting your bones: Exercise,” page 29, or more detail.) However, a well-rounded strength training program that works all the major muscle groups is most eective. his creates stresses on bones throughout the body, stimulating extra deposits o calcium and nudging bone-orming cells into action. Te bones that benefit are those that attach to the muscles that are being worked. For example, the
to 12 exercises that, combined, exercise all the major muscle groups. Tis workout does that. Four o these exercises include “power moves”—variations designed to enhance speed as well as strength. In addition, at the end, we’ve included a ew exercises that directly target balance. Our workout is designed or older adults and
standing cal raise (page 35) benefits your shin bones. b ones. Te bridge (page 35) is good or the hips and spine. Finally, strength training—particularly i it includes work on power and balance—enhances stability, which can help protect you rom alling. Like most strength training routines, the workout presented here calls or doing each exercise eight to 12 times, or repetitions (“reps”). Tose repetitions make up one set. ypically, in a complete workout, you will do two to our sets each o approximately eight
people who are new to strength training. Still, it’s wise to talk to your doctor beore trying these exercises, particularly i you’ve been diagnosed with osteoporosis. For the best results, do this workout two or three times a week, allowing at least 48 hours or your muscles to recover between workouts. For the greatest overall health benefits, also try to get 30 minutes o moderate aerobic exercise on most days o the week.
Note: Tis workout is adapted rom another Harvard Special Health Report, Strength and Power raining: A Guide for Older Adults, by Elizabeth Pegg Frates, M.D. (Harvard Medical Medical School, 2015).
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Osteoporosis
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Strength training and balance exercises for bone health | SPECIAL SECTION
Strength training exercises ll you’ll need to begin this workout is a sturdy chair with armrests, a small pillow, athletic shoes with
A
After that, add enough weight so the maximum number of repetitions you can do is eight to 12. If an exercise
lifting or pushing, since holding your breath will increase your blood pressure. As you release, r elease, breathe in. Rest for
nonskid soles, an exercise mat, and appropriate weights. Begin by choosing weights that are as light as 2 pounds for your first few training sessions, so you can concentrate on good form.
starts to feelyou easy, time to increase the weight areit’s using (within safe limits set by your doctor).
30 to 60 seconds between sets. For further tips on performing these types of exercises, see “Classic strength training,” page 30, and “Safety first,” page 31.
1
As you perform each e ach of these exercises, exe rcises, remember to breathe out when you are
Standing calf raise
Exercises the calf muscles
2
Stand with your feet flat on the floor. Hold on to the back of your chair for balance. Raise Raise yourself up on the balls of your
Stair climbing
Exercises the muscles of the buttocks and fronts of the thighs
feet, as high as possible. Hold briefly, then lower yourself. Aim for eight to 12 repetitions. Rest and repeat the set.
Holding on to the handrail for balance if necessary, walk up and down a flight of at least 10 stairs at a pace that feels comfortable. Pause Pause at the top only if you need to do so. Rest when you reach the bottom. Repeat four times.
▶ Make
harder: Once your it harder: Once balance and strength improve, tuck one foot behind the other calf before rising on the ball of your foot; repeat on the other leg. Or stand on both feet, but do not hold on to a chair ch air..
▶ Power
move: move: If If your balance is good, go up the stairs as briskly as you can and down at your normal pace for the last set.
▶ Power
move: Change the move slightly for the final set by up on thebriefly. ball ofLower your footrising quickly. Hold yourself at a normal pace.
3
Bridge
Exercises the muscles of the back, backs of the t he thighs, and buttocks
Lie on your back on a mat with your knees bent and your feet flat on the floor. floor. Put your hands next to your hips with palms flat on the floor. floor. Keep your back straight as you lift your buttocks as high as you can off the mat, using your hands for balance only. Pause. Pause. Lower your buttocks without touching the mat, then lift again. Do eight to 12 repetitions. Rest and repeat the set.
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SPECIAL SECTION | Strength
training and balance exercises for bone health
4
Triceps dip
Exercises the muscles of the backs of the upper arms, chest, and shoulders
Put a chair with armrests up against a wall. Sit in the chair and put your feet together flat on the floor. Lean forward a bit while keeping your shoulders and back straight. Bend your elbows and place your hands on the armrests of the chair, so they are in line with w ith your torso. Pressing downward on your hands, try to lift yourself up a few inches by straightening out your arms. Raise your upper body and thighs, t highs, but keep your feet in contact with the floor. Pause. Pause. Slowly release until you’re sitting back down again. Aim for eight to 12 repetitions. Rest and repeat the set. ▶ Variation:
If you don’t have a chair with armrests, sit on the stairs. Put your palms down on the stair above the one you are seated on. Press downward on the heels of your hands, lifting your body a few inches as you straighten your arms. PPause. ause. Slowly release your body until you are sitting back down again. Aim for eight to 12 repetitions. Rest and repeat the set.
▶ Power move: During move: During your last set, lift your body quickly. Slowly release until you are seated again.
6
5
Hip extension
Exercises the muscles of the buttocks and backs of the thighs
Stand 12 inches behind be hind a sturdy chair. Holding on to the back of the chair for balance, bend your trunk forward 45 degrees. Slowly raise your right leg straight out behind you. Lift it as high as possible without bending your knee. Pause.. Slowly lower the leg. Aim for eight to 12 repetiPause tions. Repeat with your left leg. This is one complete set. Rest and repeat the set. For greater effect, try adding ankle weights, available from sporting goods stores. Brands with ¼- or ½-pound weight bar inserts are best. Look for cuffs that can hold up to at least 5 pounds per leg.
Chair stand
Exercises the muscles of the abdomen, hips, fronts of the thighs, and buttocks
36
Osteoporosis
Place a small pillow at the back of your chair and position the chair so that the back of it is resting against a wall. Sit at the front of the chair with your knees bent and your feet flat on the floor and slightly apart. Lean back on the pillow in a half-reclining position with your arms crossed and your hands
and shoulders straight, raise your upper body forward until you are sitting upright. Stand up slowly, using your hands as little as possible. Slowly sit back down. Aim for eight to 12 repetitions. Rest and repeat the set.
on your shoulders. Keeping your back
quickly. Sit down again at a normal pace.
▶ Power
move: Change move: Change the move slightly for the last set by rising from the chair
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Strength training and balance exercises for bone health | SPECIAL SECTION
7
Overhead press
Exercises the muscles of the shoulders, up per back, sides of the rib cage, and backs of the upper arms
Stand with your feet slightly apart. Hold a dumbbell in each hand at shoulder height (your elbows should be bent and the weights should be about six inches from your body). Hold the weights so your palms are facing forward. Slowly lift the weights straight up until your arms are fully extended. Pause.. Slowly lower the dumbbells to shoulder level. Do Pause eight to 12 repetitions. Rest and repeat the set.
9
Double biceps curl
Exercises the front upper arm muscles
8
Side leg raise
Exercises the muscles of the hips and sides of the thighs
Wearing a weight on your right ankle, stand behind a sturdy chair with your feet fee t together. Hold on to the back of the chair for balance. Slowly raise your right leg straight to the side until your foot is eight inches off the floor. Keep your knee straight. Pause. Slowly lower your foot to the th e floor. Do eight to 12 repetitions. Repeat with the left leg. This is one complete set. Rest and repeat the set.
10
Forward fly
Exercises the muscles of the shoulders and upper back
Stand or sit holding dumbbells down at your sides with your palms facing inward. Slowly
Sit in a chair holding weights about 12 inches in front of your chest. Your Your elbows should be up and slightly bent ben t and your palms should be facing each other (as if your arms are wrapped around a large beach ball). Lean forward at a slight
bend both elbows, lifting the weights toward your upper chest. Keep your elbows close to your sides. As you lift, rotate your palms so they face your shoulders. Pause. Slowly lower your arms to the starting position. Do eight to 12 repetitions. Rest and repeat the set.
angle in the chair, bending from your hips and keeping your back straight. Now, pull the weights apart while trying to bring your shoulder blades as close together as possible. Let the movement pull your elbows back as far as possible. Pause. Return to the starting position. Do eight to 12 repetitions. Rest and repeat the set.
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Osteoporosis
37
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SPECIAL SECTION | Strength
training and balance exercises for bone health
Balance exercises An osteoporosis workout should ideally have two goals—shoring up bones, and improving balance to prevent
including the standing calf raise (page 35), hip extension (page 36), chair stand (page 36), and side leg raise
balance. But the following four exercises are more specifically targeted at making you steadier on
falls. Many of the previous exercises,
(page 37), are also useful for improving
your feet.
1
Thigh raise
Stand with your hands on your hips. Raise one foot, keeping a toe on the floor. Keeping your back straight, raise your knee until your thigh is parallel to the floor (your foot will be lifted off the floor). Pause. Pause. Lower the leg to the starting position. Do eight to 12 repetitions. Repeat with the opposite leg. This This is one complete set. Rest and repeat the set. Note: Ankle weights are optional, but if you use them for this exercise, they will provide added resistance and increased muscle strengthening. ▶ Make
it harder: Stand next to a chair and hold on to the back of it for balance, if necessary. necessary. Raise the knee that’s farthest away from the chair up toward your chest. Pause. Pause. Lower the leg. Do eight to 12 repetitions. Rest and repeat the set. Repeat with your other leg.
3
Reverse lunge (not shown)
Stand up straight, with your feet together and weight evenly distributed on both feet. Put your arms at your sides. K Keeping eeping your left foot where it is, step back on the ball of your right foot and bend both knees, sinking into a lunge, with your right knee pointing to the floor. floor. If this is too difficult, don’t put your right foot so far back, and don’t bend your knees as much. Return to the starting position. Repeat on the other side, performing 10 repetitions on each side.
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Osteoporosis
2
Tree pose p ose (not shown)
This popular yoga pose is good for developing balance. Stand straight up, feet hip-width apart and weight evenly distributed on both feet. Put your arms at your sides. Then slowly shift your weight to your right leg while bending the left knee. Lift your left foot and place it on the inside of your right leg, either above or below the knee. To To help you balance, place the sole of your left foot firmly against your right leg and press your right leg against your left foot. Brace your abdominal muscles as you bend your elbows and bring your hands up in front of your chest in a prayer position. Hold. Return to the starting position, and then repeat while standing on your left leg. ▶ Make
easier: If If this pose is too hard, it easier: place your foot at the calf or ankle. The only place you shouldn’t put it is against the knee.
4
Heel-to-toe walk (not shown)
Position your heel directly in front of the toes of the opposite foot each time you take a step. Heel and toes should actually touch as you walk forward for eight to 12 steps. If necessary,, steady yourself by putting one hand on a sary counter as you walk. Then work toward doing the exercise without support. Repeat two to four times.
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Protecting your bones: Medicati Medication on utrition and weight-bearing exercise can do some phonates typically prescribed or osteoporosis are o the heavy lifing when it comes to maintaining alendronate (Fosamax), risedronate (Actonel), and bone strength, but medication also plays a key role, ibandronate (Boniva). Once they were available only in daily doses, but thanks to new ormulations, more especially or women who have reached menopause. Because medicines can have risks, they aren’t patients are opting or weekly or monthly versions recommended or everyone. According to National because o the convenience. One o the medications in Osteoporosis Foundation guidelines, your doctor is this class, zoledronic acid (Reclast), can even be taken most likely to put you on a bone-strengthening drug just once a year via an intravenous inusion. With an inusion, the medicine is delivered into a vein through i you a needle or a tube called a catheter catheter.. Te inusion takes • have ractured a hip or vertebra about 15 minutes. • have a -score o –2.5 or less at the lumbar spine, Like most o the medications approved or treating hip, or emoral neck • are 50 or older with a -score between –1 and –2.5, osteoporosis, bisphosphonates reduce bone resorption,
N
Since the mid-1990s, when the FDA approv approved ed the first
slowing bone loss and producing modest increases in bone density. Tey accomplish this by binding to hydroxyapatite and interering with bone-depleting osteoclasts. Osteoblasts then have an opportunity to fill in more o the trenches lef by osteoclasts. As a result, bisphosphonates reduce hip, wrist, and spinal ractures. Tey have become an attractive alternative to hormone therapy, which was once widely used or stemming bone loss but has allen out o avor because o saety concerns (see “Hormones,” page 46). I taken correctly, oral bisphosphonates do not cause side effects in most people. But i they are not taken correctly, they may be hard to digest and can cause nausea, heartburn, or irritation o the stomach or esophagus (see “How to take Fosamax, Actonel, and Boniva properly,” page 41). Many people find these instructions cumbersome. Te inconvenience, coupled with the act that osteoporosis doesn’t have any symptoms, causes some people to question whether they need medication at all and to give up treatment. Others continue with therapy but ail to take their medication properly. Experts hope that the development o more convenient ormulations o
bisphosphonate drug, this class o drugs become the first choice o doctors or treating orhas preventing osteoporosis (see able 6, page 44). Te oral bisphos-
bisphosphonates willpeople translate compliance, meaning that more willinto takebetter their medications as directed.
and a 10-year hip racture risk o 3% or more or a 10-year major osteoporosis-related osteoporosis-related racture risk o 20% or more based on your FRAX score (see “How likely are you to break a bone? Your FRAX score and more,” page 17). Tis chapter lists the major types o medications used or osteoporosis. Which one is right or you? Tat depends on your individual health status, racture risk, and treatment preerences. No matter which medicine your doctor prescribes, your goal isn’t to stay on it indefinitely. Te doctor will likely do repeat tests o bone density a year or two afer starting you on the drug, and then every two years afer that. You might also have blood or urine tests or biochemical markers that determine how well the drug is working. Tese bone assessments will help your doctor determine whether and how much the drug is helping, and i it’s time to stop taking it or shif to another medication.
Bisphosphonates
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Osteoporosis
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While bisphosphonates are usually well tolerated, some people taking these medications develop severe or even incapacitating bone, joint, or muscle pain. According to a warning rom the FDA, this pain can occur days, months, or even years afer starting a bisphosphonate; or this reason, physicians sometimes attribute the pain to other medical conditions, resulting in prolonged discomort and delayed treatment. While some people on bisphosphonates report that the pain disappears completely as soon as they stop taking the medications, others have ound that the pain ebbs slowly or only partially. Other reports have suraced that bisphosph bisphosphonates onates may be linked to unusual bone ractures, damage to the jawbone, or disturbances in heart rhythm. However, some o these effects remain unproven, and problems like these are very rare (see “How sae are bisphosphonates? A doctor weighs in,” page 42). As with any prescription, report new or unusual
bone mass in the spine and hip as effectively as hormone therapy, but without the same risks. It travels preerentially to spots where bone turnover is high, such as the hips and spine. Studies suggest that alendronate is sae and effective or at least 10 years. And it yields results quickly. A ollow-up o the Fracture Intervention rial, an important study conducted in the 1990s, ound that alendronate was able to reduce the risk or spinal ractures within a year year.. Furthermore, the beneits seem to linger even ater people stop using the medication. In another ollow-up to the Fracture Intervention rial, researchers compared women who had taken alendronate or five years with women treated or 10 years. In those who took the drug or five years and then stopped, bone mineral density showed a small decline but remained at or above where it was at the start o treatment. Moreover, racture risk or the most
symptoms to your doctor immediately. Let your physician decide whether or not the symptom is a concern instead o dismissing it yoursel.
part did not rise, except or a small increased risk o a vertebral racture, and was generally comparable to that in women who continued to take alendronate or the ull 10 years. Te researchers concluded that many women may be able to stop using the medication afer five years without putting themselves in greater jeopardy o breaking a bone. However, they noted that women at high risk o spinal ractures may benefit rom continuing the treatment beyond that five-year time rame.
Alendronate (Fosamax) Alendronate is FDA-approved or the prevention and treatment o osteoporosis in postmenopausal women, the treatmen t reatmentt o glucocorticoid-indu glucocorticoid-induced ced osteoporosis, and the treatment o osteoporosis in men. It is available as a pill that’s taken daily or as either a liquid or pill that’s taken once a week. Another version combines alendronate and vitamin D. A generic version o alendronatee is also available. alendronat Since 1995, when alendronate received its initial FDA approval, studies have consistently shown that it can slow or even halt bone loss, increase bone density, and reduce the risk or spinal and hip ractures. In a systematic review o clinical trials involving a total o more than 12,000 women, treatment with alendronate reduced the overall risk or vertebral ractures by 45% and hip ractures by 40%, compared with not taking any medication. However, it’s important to note that the medication had this effect only in women who had
Risedronate (Actonel) Like its cousin alendronate, risedronate is approved to prevent and treat osteoporosis in postmenopausal women, and it may be used to prevent or treat glucocorticoid-related osteoporosis in men and women and to treat osteoporosis in men. It is available as a daily pill, a weekly pill, or a tablet taken once a month. Also like alendronate, risedronate has been shown to impede bone loss, increase bone b one mineral density density,, and reduce the risk or ractures. A handul o studies, including one randomized
already had a racture beore the study. Alendronate is also eective or prevention. Studies have ound that the medication increases
clinical trial, haveIndirectly compared alendronate and risedronate. the clinical trial, once-weekly alendronate raised bone mineral density in
40 Osteoporosis
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How to take Fosamax, Actonel, and Boniva properly
S k c o t s k i h n T | s e g a m I y d n a c e y E ©
ince alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva) can be difficult to digest, people taking these medications must follow instructions carefully to avoid unpleasant side effects such as heartburn, nausea, or difficulty swallowing. First thing the morning, me dicamedication on an in empty stomach take with the a large glass of water (at least 8 ounces) and then remain upright for at least 30 minutes (60 minutes for once-a-month Boniva). During this time, avoid eating, drinking, or taking another medication. It’s important to take the medication with water, water, rather than coffee or orange juice, both of which can interfere with your body’s ability to absorb and use the drug. Most people tolerate these medications well when they take them as instructed. In fact, side effects are uncommon among people taking bisphosphonates in clinical studies. Perhaps these study participants are more likely to take their medications exactly as directed.
The consequences of not taking alendronate properly became evident a few months after it was on the market. The manufacturer, Merck, notified physicians that women were experiencing more esophagitis, ulcers, ulcers, and other gastrointestinal side effects than reported during clinical trials. The company attributed these side effects to patients failing to drink enough water with the pills or lying down in bed after taking the medication. Although it can be a hassle to take bisphosphonates as directed, the extra care can pay off by helping you sidestep unpleasant side effects. While bisphosphonates are quite effective in preventing fractures, the oral forms may not be the best choice for those who have recurrent heartburn, acid reflux, esophagitis, sstomtomach ulcers, or difficulty swallowing. People who have Barrett’s esophagus should not take oral bisphosphonates. If you have any of these conditions, ask your doctor about taking injectable or intravenous osteoporosis medications instead.
postmenopausal women more than did risedronate afer a year o treatment, although both drugs reduced racture risk the same amount. Like alendronate, risedronate works relatively quickly and helps to reduce bone loss and ractures in men as well as women.
to short-lived flu-like symptoms in a small percentage o people receiving the intraveno intravenous us version.
injected ibandronate doesn’t seen causewith the heartburn and esophageal problems the oral bisphosphonates. However, the drug has been linked
effects, including ever, and joint aches, and headache or several daysmuscle afer the inusion. Te drug may also temporarily affect kidney unction.
Zoledronic acid (Reclast) Zoledronic acid (Reclast) is a bisphosphonate given as a 15-minute inusion once a year or the treatment o Ibandronate (Boniva) osteoporosis, or every other year or preventing bone Ibandronate is approved or the prevention and treat- loss. When zoledronic acid earned FDA approval in ment o postmenopausal osteoporosis. It is available in 2007, many women wondered whether they should a daily or monthly tablet or as an injection every three switch over to it. Not only was this new drug more months. Like the other bisphosphonates, ibandrona ibandronate te convenient or patients, but it also showed an impresincreases bone mineral density and reduces the risk o sive ability to reduce ractures and boost bone density. ractures o the spine in women with postmenopausal In a study published in Te New England Journal of osteoporosis. Te side effects o ibandronate are simi- Medicine, women with osteoporosis receiv received ed either an lar to those t hose o alendronate and risedronate, including annual inusion o zoledronic acid or a placebo. Over heartburn, ulcers, irritation o the esophagus, and di- three years, the drug reduced the risk o vertebral ractures by 70% and hip ractures by 41%. Women on ficulty swallowing. he quarterly intravenous injection o the drug also enjoyed higher bone mineral densities at ibandronate is currently FDA-approved only or the the hip and spine. treatment o postmenopausal osteoporosis. Because While these results are promising, some women the medication bypasses the gastrointestinal tract, taking zoledronic acid may experience significant side
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Osteoporosis
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Strontium ranelate Strontium ranelate (Protelos) is a compound that incorporates the element strontium, which is ound in trace amounts throughout the skeleton. Protelos is believed to prevent ractures by both reducing bone breakdown and increasing bone ormation. Studies find it may be particularly effective in managing osteoporosis risk in women ages 75 and older.
Currently, strontium ranelate isn’t available in the United States. And while it is sold in Europe, the European Medicines Agency has advised limiting its use to people who haven’t been helped by other medicines. Because o its potential or increasing the risk o serious heart problems, the drug is not recommended or women with heart disease, a history o blood clots, or high blood pressure.
How safe are bisphosphonates? A doctor weighs in Media reports have fueled concerns about a connection between bisphosphonates and some troubling side effects, leading many women to ask their doctors whether tthey hey should continue taking these medications. To help sort facts from unfounded fears, Dr. Dr. David Slovik, medical editor of this report re port and an endoc endocrinologist rinologist at Massachusetts General Hospital, answers some of the most common questions he hears from his patients. Will Fosamax make my bones weaker? Dr. Slovik: There Slovik: There have been reports that some women taking alendronate (Fosamax) experienced unusual bone fractures or delays in the healing of fractures. This led researchers to question whether the drug may
alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva) for osteoporosis. It’s important to remember, remember, though, that compared with the millions of women taking bisphosphonates, the number of osteonecrosis cases is tiny. tiny. According to one estimate, the risk
have weakened their bones.bone In these cases,toitsuch mayabedegree that the bisphosphonate decreases turnover that the body is much slower in repairing microdamage that occurs naturally to bone. Fractures Fractu res may be related to dose and duration of treatment. The longer you take the medicine and the higher the dose, tthe he more likely you are to experience an unusual fracture. Still, any possible connection between alendronate, or other bisphosphonates, and unusual bone fractures is unproven, and more study is needed. However, that finding has to be balanced by the fact that even if alendronate is responsible, these events are extremely rare. Someday we may be able to determine who is more likely to suffer side effects from a particular drug. But in the meantime, it’s important to keep in mind that more than two decades of
is between one in 10,000 in 100,000 per year. bot-a tom-line terms, that meansand forone every 10,000 people whoIntake bisphosphonate for a year, one may develop bone loss in the jaw. Still, I think it’s a good idea to have a dental exam and complete any necessary extractions or implants before you start taking a bisphosphonate. If you are already taking one, tell your dentist so she or he can consider it in planning your treatment. Also, be aware of the symptoms of osteonecrosis, osteonecr osis, which include pain, swelling, or infection of the gums or jaw; gums that aren’t healing; loose teeth; and numbness in the jaw. jaw.
research alendronate and similar overwhelmingly concludedonthat bisphosphonates are drugs highlyhas effective at improving bone density and reducing fractures. Can bisphosphonates damage my jawbone? Dr. Slovik: There Slovik: There has been concern about a connection between bisphosphonates and the death of bone tissue (osteonecrosis) in the jaw. While no clear cause-and-effect relationship has been established, and scientists are unsure why some patients develop osteonecrosis of the jaw, there are good reasons to suspect bisphosphonates play a role. Just as with atypical fractures, the dose and duration of use play a role in osteonecrosis risk. Most of these cases of osteonecrosis—about 94%—have involved cancer patients receiving intravenous drugs such as pamidronate (Aredia) and a type of zoledronic acid (Zometa) in doses much higher than are used for the treatment of osteoporosis. But this side effect also has been reported, with much lower frequency, in patients taking oral bisphosphonates such as
42 Osteoporosis
Is it true some osteoporosis drugs can cause atrial fibrillation? Dr. Slovik: Atrial fibrillation is a common heart rhythm disturbance that affects more than two million people. Considering the millions of people who take bisphosphonates, iitt would be surprising if there weren’t some overlap with this very common heart problem. Still, atrial fibrillation as an adverse event was noted in the initial zoledronic acid Pivotal Fracture Trial Trial in 2007, but it has not been seen in other trials of zoledronic acid (Reclast) or other bisphosphonates. These initial results prompted the FDA to go back to data involving nearly 40,000 clinical trial participants who took one of these drugs or a placebo. Ultimately, Ultimately, officials didn’t find a link between bisphosphonates and atrial fibrillation. Meanwhile, regardless of whether or not you take a bisphosphonate, contact your doctor immediately if you experience any of the following symptoms: a racing heart, fluttering sensation in your chest, chest pain, or unexpected shortness of breath.
Do bisphosphonates put me at higher risk for breaking my thighbone? Dr. Slovik: The controversy over whether bisphosphonate use is linked to thighbone (femoral) fractures dates back to around
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SERMs Bisphosphonates are not the only game in town. Bone Bisphosphonates loss can also be treated with a class o drugs known as selective estrogen receptor modulators (SERMs). Tese are ofen called “designer estrogens”—or estrogen agonists/antagonists—because they mimic some o estrogen’s positive effects without also causing some o the negative consequences (see “Hormones,” page 46).
In the body, SERMs attach to special proteins, called receptors, on the suraces o cells, in the way a key would fit into a lock. When a natural estrogen molecule binds to such a receptor, it stimulates a response in the cell—and not always a good one. For example,, estrogen can stimulate the growth o certain example kinds o malignant tumors, including some breast, uterine, and ovarian cancers.
2007 or 2008 when reports started to emerge of an association between these unusual breaks without major trauma in women who had been taking alendronate for about five years. Since then, there have been other reports of so-called low-energy thighbone fractures in patients who had been on long-term bisphosphonate therapy.. (Low-energy fractures occur from a fall from standing therapy height or less.) Sometimes patients complain of achiness or pain in their thighs or hips before the fracture occurs. Some researchers speculate that continued suppression of bone remodeling by alendronate and other bisphosphonates may have encouraged microdamage to the bone. In the short
After taking into consideration the combined results of these and other studies, a task force of the American Society for Bone and Mineral Research in 2016 recommended that doctors re-evaluate their patients after five years on oral bisphosphonates, or three years on intravenous bisphosphonates. For some women—including those who have a high fracture risk score, a low hip T-score, or a past fracture—it may be worth staying on the drug for longer (up to 10 years for oral bisphosphonates, and six years for intravenous bisphosphonates). Women who aren’t at such high risk may be able to take a two- or three-year holiday after three to five years of treatment, without suffering significant bone degeneration.
term, slowing bone resorption increases bone density because new bone formation continues. But over time it may impair new bone formation and reduce the bone’s ability to repair microscopic cracks from normal wear and tear. Ultimately bone may become more brittle and less resilient to wear and tear. tear. But at this point, the incidence of atypical femoral (thighbone) fractures is very low, low, particularly in comparison with fractures of the hip, spine, and other areas, and a causal relationship has not been established.
Whatever you do, don’t simply stop taking the drug without first talking to your doctor. doctor. Although we know that bisphosphonates stay in bone for years, we have little solid evidence to guide us in this area, so it’s not clear whether a drug holiday will lower the risk for long-term effects. If you do decide to stop the medication, be sure to have your bone density tested after a year or two. If it has declined significantly, you can always resume therapy, although when to do so is unclear and awaits further study.
Should I consider taking a “drug holiday” from bisphosphonates? Dr. Slovik: This is a very popular question among patients. Limited research on the subject has made recommendations challenging. Yet Yet based on the available evidence, experts have offered some guidance on whether a drug holiday is a wise choice for postmenopausal women with osteoporosis. The first study to suggest that some women can eventually stop or take a drug holiday was the Fracture Intervention Trial Trial Long-term Extension (FLEX) study, in which women who had taken alendronate for at least five years were randomly assigned to continue the drug or switch to a placebo for five more years. Those who discontinued the drug showed a gradual decline in bone density, but at 10 years their bone density was still above baseline. They had a slight increase in the risk for clinical spine fractures, but the rate of hip fracture, a far more serious injury, was the same in the two groups. The HORIZON extension, which investigated the long-term safety and effectiveness of zoledronic acid in postmenopausal women with osteoporosis, found that women who stuck with six yearly injections had fewer vertebral fractures than those who switched to a placebo after three years. w w w . h e a l t h . h a r v a r d . e d u
Can I safely take bisphosphonates after fracture surgery? Dr. Slovik: Bisphosphonates are known for their ability to strengthen bones and reduce the risk of fractures. Yet there has h as been some debate over whether it’s wise to take them shortly after you have surgery to repair a fractured bone. In years past, experts raised concerns that these drugs might interfere with bone remodeling and delay recovery. A 2015 review and metaanalysis of studies counters these concerns. The authors found that taking bisphosphonates had no adverse effect on fracture healing. And, they said the ability of these drugs to reduce bone resorption should lower the rate of fractures following surgery. What’ What’ss your overall take on bisphosphonates? Dr. Slovik: In Slovik: In the years since bisphosphonate drugs first came on the market for the treatment of osteoporosis, millions of women and men have benefited from them. According to recent research, there’s been a decrease in hip fractures. That That is likely due in large part to the use of bisphosphonates, along with our ability to diagnose and treat osteoporosis osteoporo sis earlier earlier.. It’s clear to me that these medications play an important role in building bone strength and preventing fractures. And And in my eexperience xperience they are usually quite safe. Major side effects are rare if they are taken properly, for the shortest time necessary to achieve the beneficial effect and with collaboration between the patient and physician. Osteoporosis
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But SERMs don’t fit the cell receptors quite as perectly as natural estrogen molecules. Tat turns out to be good. goo d. It means that SERMs have different effects in different parts o the body, depending on the type o tissue—presumably because the estrogen receptors on these tissues are somewhat different. As a result, SERMs have positive effects on building bone, but without promoting cancer. Raloxifene (Evista) Raloxiene is the only SERM currently approved or preventing and treating osteoporosis, but others are in development. Like estrogen, raloxiene slows bone loss; unlike estrogen, it does not increase the risk or uterine cancer, and it actually protects against breast
cancer. Raloxiene is also approved to reduce the risk o invasive breast cancer in women who have postmenopausal osteoporosis or who are at high risk o breast cancer. In clinical trials, raloxiene slowed bone loss and reduced spinal ractures by 30% to 50%. And in a major clinical trial, the Multiple Outcomes o Raloxiene Evaluation (MORE), raloxiene worked as well as tamoxien (Nolvadex) in reducing the risk o breast cancer in high-risk women, and apparently with ewer side effects. Te MORE study also suggested that raloxiene might protect some women rom heart problems. o explore this urther, researchers launched the Raloxiene Use or the Heart (RUH) study. Te
Table 6: Medications approved for osteoporosis GENERIC NAME
TYPE OF PRODUCT/
(BRAND NAME)
FR EQU ENC Y OF U S E
A P P RO V E D U SE S
BE N E F I T S
SI D E E F F E C T S / C O M M E N T S
alendronate (Fosamax, Fosamax Plus D)
Daily tablet or weekly liquid or tablet.
Prevention and treatment of osteoporosis in postmenopausal women. Treatment Treatment of osteoporosis in men. Treatment Treatment of glucocorticoid-induced osteoporosis in men and women.
Increases bone density at the spine and hip. Reduces the risk for spine and hip fractures.
Difficult to digest. May cause nausea, heartburn, or irritation of the esophagus if not taken properly. Generally well tolerated.
ibandronate (Boniva)
Daily or monthly tablet, or quarterly intravenous injection.
Prevention and treatment of osteoporosis in postmenopausal women (oral version). Tr Treatment eatment of osteoporosis in postmenopausal women (intravenous version).
Increases bone density. Reduces the risk for spine fractures.
The oral versions can be difficult to digest; may cause ulcers, nausea, heartburn, or irritation of the esophagus if not taken properly. TThe he intravenous preparation may cause fever and flu-like symptoms.
risedronate (Actonel, Atelvia)
Daily, weekly, or monthly tablet.
Prevention and treatment of osteoporosis in postmenopausal women. Treatment Treatment of osteoporosis in men. Treatment Treatment of glucocorticoid-induced osteoporosis in men and women.
Increases bone density at the spine and hip. Reduces the risk for spine and nonvertebral fractures.
Difficult to digest. May cause nausea, heartburn, or irritation of the esophagus if not taken properly. Generally well tolerated.
zoledronic acid (Reclast)
15-minute infusion, given annually for treatment or every two years for prevention.
Prevention and treatment of osteoporosis in postmenopausal women. Treatment Treatment of osteoporosis in men. Treatment Treatment of glucocorticoid-induced osteoporosis in men and women.
Increases bone density. Reduces the risk for spine and hip fractures.
May cause fever, flu-like symptoms, muscle and joint aches, and headache for several days after the infusion. Kidney function may be transiently affected.
Treat Treatment ment of osteoporosis in postmenopausal women and men.
Increases bone Reduces the riskdensity. for spine and hip fractures.
An increase in infections, especially of the skin, has been reported.
Bisphosphonates
Monoclonal antibody denosumab (Prolia)
Subcutaneous injection every six months.
continued on page 45
44 Osteoporosis
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trial, involving some 10,000 women, did not find any change—either an increase or decrease—in the risk o heart attacks or other heart problems with the use o raloxiene. But it ound reason or caution. While raloxiene did not increase the overall risk o stroke, women using the drug who did have a stroke were more likely to die rom it. Also, the risk o blood clots in the legs was higher. On the plus side, the women were much less likely to develop invasive breast cancer, c ancer, and were less likely to suffer a vertebral racture. One lesson to take home rom this research is that raloxiene, like estrogen, has wide-ranging effects on the body—some desirable, some not. I your doctor recommends this drug to you, make sure you ully understand the risks and benefits.
Monoclonal antibodies Human antibodies, manuactured with genetically engineered cells, can strongly block the activity o osteoclasts. So ar there is only one approved drug in this class. Denosumab (Prolia) Te FDA approved denosumab (Prolia) in 2010 or the treatment o osteoporosis in postmenopausal women who are at high risk o racture and later approved it or treating osteoporosis in men. It is not approved or prevention. It is taken every six months as a subcutaneous (under the skin) injection, like a flu shot. Denosumab is a human monoclonal antibody that acts to reduce the ormation and action o
Table 6 continued GENERIC NAME
TYPE OF PRODUCT/
(BRAND NAME)
F R E Q U E N C Y O F U SE
A P P R OV E D U S E S
B ENEF IT S
S I D E EFFEC T S / C O MMEN T S
Selective estrogen receptor modulator (SERM) Daily ttaablet.
Prevention aannd ttrreatment of of osteoporosis in postmenopausal women.
Increases bone density, although not as much as the bisphosphonates. Reduces the risk for spine fractures. Reduces risk for invasive breast cancer.. Lowers LDL (bad) cancer cholesterol.
Side effects are uncommon, but can include hot flashes, leg cramps, and blood clots.
calcitonin (Calcimar, Fortical,
Injection, given daily or every other
Treatment of postmenopausal Treatment osteoporosis.
Increases bone density, but not as dramatically
Long-term safety is under evaluation. In the short term, the injected form
Miacalcin)
day. spray.Daily nasal
as any of the other approved medic medications. ations. Reduces the risk for spine fractures.
can cause flushing of the urination, face and hands, nausea, increased and rash. The The nasal spray can ccause ause a runny nose.
estrogen (Activella, Climara, Estrace, Estraderm, Estratab, FemHRT, Ogen, Premarin, Premphase, Prempro, Vivelle-Dot, others)
Tablets and patches.
Prevention of osteoporosis in women.
Increases bone density. Reduces the risk for fractures. Helps alleviate the symptoms of menopause, including hot flashes, vaginal dryness, and insomnia. Improves cholesterol levels.
Estrogen alone increases the risk for stroke and uterine cancer. Prempro, an estrogen-plus-progestin formula, increases the risk for heart attack, stroke, blood clots, and breast cancer; other estrogen-plus-progestin formulas have not been studied as extensively, so it is unclear if they carry the same risks.
teriparatide (Forteo)—synthetic
Dai aily ly in inje ject ctio ion. n.
Tre reat atm men entt of of oost steo eopo porros osis is in men and postmenopausal
May double the rate of bone formation. Reduces
Must be taken as an injection. Because effects appear to wane and
women. Treatment Treatment of glucocorticoid-induced osteoporosis in men and women.
the risk for spine and nonvertebral fractures.
long-term safety data are lacking, should not be prescribed for more than two years.
raloxifene (Evista)
Hormones
parathyroid hormone, or PTH
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Estrogen products (Premarin, Estrace, others) Many women use hormones in the years leading up to and ollowing menopause to ease hot flashes, insomnia, and vaginal dryness. At one time hormone therapy was also widely prescribed to reduce menopausal bone loss. Its use or this purpose has allen sharply, however, since the Women’s Health Initiative—the
taking a combination o estrogen and progestin were ound to be at higher risk o breast cancer, heart disease, stroke, and blood clots in the veins and lungs. Critics o this study say the risks were exaggerated. Tey point out that only one hormone preparation was used in each arm o the trial and that other ormulas may not carry the same risks or benefits. Others note that the women who suffered the most health problems in the study began taking the hormones in their 60s and 70s, long afer the start o menopause menopause.. Nevertheless, the North American Menopause Society and other authorities recommend taking the smallest eective dose o hormones or the shortest period o time—and only i you have no contraindications (reasons not to take it), such as a history o breast cancer. Since by definition, taking hormones to preserve bone involves long-term use o the therapy, most doctors no longer prescribe hormone therapy just or preventing osteoporosis—
only large, long-term randomized controlled trial o hormone therapy—was halted in 2002, afer women
especially since other drugs can effectively prevent and treat the problem.
osteoclasts, the cells that break down bone. In clinical trials, denosumab reduced bone resorption, increased bone density, and reduced ractures in both men and women. It represents a new option or people who have trouble taking oral bisphosphonates or other standard drugs.
Hormones Naturally occurring hormones can have important effects on bone. So can synthetic ones.
New osteoporosis drugs in the pipeline
A
s osteoblasts (bone-building cells) and osteoclasts (boneremoving cells) go about their work keeping your bones healthy,, they use a variety of biochemical signals to “talk” to healthy each other. Tweaking the activity of these messengers with medicine is one way to intervene if the process gets out of balance, and you start losing more bone than you gain. Another way is to block the bone-dissolving enzymes that help break down old bone. Sclerostin. This protein is under development as a target for Sclerostin. This bone-loss drugs. Bone cells produce sclerostin as a message to tell the osteoblasts to slow down. By blocking this chemical conversation, drugs could trick the body into continuing to make new bone. A monoclonal antibody designed to bind to and block sclerostin is currently being tested.
mineral density in the lumbar spine and total hip compared with placebo among postmenopausal women. Odanacatib and several other cathepsin K inhibitors have been studied in clinical trials. However, However, none has come to market yet, in part because safety issues are still being evaluated. Human parathyroid hormone–related protein (hPTHrP). Drugs like bisphosphonates, which decrease bone resorption, significantly reduce fracture risk, but they can’t stimulate new bone formation. Anabolic (bone-building) agents such as the parathyroid hormone teriparatide (Forteo) offer the advantage of stimulating osteoblasts to trigger new bone formation. A new analog of human parathyroid hormonerelated protein (hPTHrP) is being studied for the treatment of postmenopausal osteoporosis. In one recent study, study, abaloparatide, an hPTHrP drug under investigation, increased bone density in the lumbar spine, total hip, and femoral neck even better than Forteo. Forteo.
Cathepsin K inhibitors. inhibitors. Cathepsin Cathepsin K is an enzyme produced by osteoclasts that helps break down the structure of bone, releasing the minerals stored within. Drugs that block cathepsin K’s bone-dissolving activity could help reduce bone loss. A new medication, odanacatib, is in advanced clinical trials. A 2015 study of this drug was stopped early, early, after researchers found evidence of “robust efficacy and a
New drug delivery methods For women who rely on the bone-protective abilities of drugs like the bisphosphonates but dread the needle or multiple pill instructions, researchers are developing other ways to
favorable benefit/risk profile. ” The The treatment significantly reduced vertebral andprofile.” hip fractures and increased bone
simplify drug drugs delivery, such as patch that would deliver osteoporosis through thea skin.
46 Osteoporosis
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Tat said, i you do choose hormone therapy to combat menopausal symptoms, you can expect a boost to bone health, since hormone therapy both increases bone strength and reduces the risk o racture in the spine and hip—at least during the time you’re using it. Unortunately, as soon as you stop taking hormones, the bone benefit begins to ade, with bone mineral density dropping back to baseline within a year or two. Teriparatide (Forteo) Te FDA has approved teriparatide (Forteo), a synthetic version o parathyroid hormone, or the treatment—but not prevention—o osteoporosis in both men and postmenopausal women and or the treatment o glucocorticoid-indu glucocorticoid-induced ced osteoporosis. Parathyroid hormone is produced naturally in the body and works in several ways to increase the amount o calcium in circulation. It promotes calcium absorption in the intestines and slows its excretion
by the kidneys. While too much o the hormone accelerates bone loss, low doses given intermittently can increase bone mass and strengthen bone (see Figure 10, below). Unlike medications that slow the rate o bone loss, teriparatide actually helps build new bone by increasing the activity and number o bone-building osteoblasts.
Figure 10: Parathyroid hormone and bone A
B
These scanning electron microscopy pictures show bone biopsies taken from a 64-year-old woman, before (A) and after (B) parathyroid hormone treatment. Improvements Improvements can be seen in interior structure (microarchitecture) and outer (cortical) thickness. Reproduced from Dempster DW, et al. Journal of Bone and Mineral Research (Oct. Research (Oct. 2001), Vol. Vol. 16, No. No. 10, pp. pp. 1846–53, with permission of the American Society for Bone and Mineral Research. w w w . h e a l t h . h a r v a r d . e d u
And it can increase bone mass dramatically. One study ound that teriparatide was more effective than alendronate in increasing bone mineral density and decreasing ractures in postmenopausal women with osteoporosis. eriparatide appears to reduce vertebral ractures by 65% to 70% and to reduce nonvertebral ractures by about 50%. Because teriparatide builds bone while bisphosphonates reduce bone resorption, doctors have wondered i giving both drugs—at the same time or sequentially—would have a greater effect than either alone. Clinical trials on the subject are ongoing. eriparatide is recommended or people who have osteoporosis and are at high risk or a racture. Tis includes people who have already suffered a nontraumatic racture o the spine, hip, or another major bone, as well as people with multiple risk actors or ractures (such as a amily history o osteoporosis, poor calcium intake, and a -score o less than –2.5). Te drug is available only as a once-a-day injection, and it is recommended that treatment be limited to no more than two years. Some experts recommend using teriparatide alone or two years and then switching to a bisphosphonate or other antiresorptive agent to protect or augment any gains in bone density. Side effects can include nausea, dizziness, and leg cramps. Studies in rats have ound an increased risk o bone cancer, but at much higher doses than are used in people. eriparatide has been around or more than a decade, and to date, no studies have shown that it increases bone cancer risk in humans. Calcitonin (Miacalcin, Fortical, others) Calcitonin (Miacalcin, Fortical, others) is approved only or the treatment, not the prevention, o osteoporosis. Tis hormone is produced by the thyroid gland, but its physiologic role in humans is not established. Salmon is the most common source o calcitonin used in medications. When administered—as either an injection or a nasal spray—it inhibits bone resorption by osteoclasts. Although calcitonin has been tested in a large
number o clinical trials and has been used to treat women with bone loss or many years, it doesn’t build bone as robustly as other medications. Women who Osteoporosis
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take it usually see a slowing o bone loss or just a slight increase in bone mass. It reduces the risk or spinal ractures but hasn’t been shown to lessen the risk or other kinds o ractures. Tere also is some evidence that calcitonin has painkilling properties. People who take calcitonin by injection generally experience more side effects than do those who use the nasal spray version. Side effects include flushing in the ace and hands, dizziness, nausea, rash, and increased urination. Te spray ormulation can cause nasal symptoms, including a runny nose or nasal crusts and irritation. In addition to these minor side effects, a ew studies ound slightly higher cancer risks in people
48 Osteoporosis
taking the drug. Te data were not specific enough to single out particular types o cancer. But in 2012, the European Medicines Agency recommended that calcitonin not be used to treat osteoporosis because o the overall increase in rrisk. isk. Canada’s health agency took calcitonin nasal spray off the market in 2013. Afer reviewing the drug’s saety, however, the FDA ound insufficient evidence to justiy pulling calcitonin rom the U.S. market. Instead, it recommends that calcitonin be used only in cases where people can’t tolerate or don’t want to take other osteoporosis drugs. I you’re considering this treatment, weigh its potential side effects careully when making your decision.
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Coping with fractures reaking a bone is ofen painul and rightening. Recovery can take months, and a break can threaten your ability to perorm simple everyday tasks such as carrying groceries, making your own meals, or cleaning. But there is a lot you can do to recover rom a racture and prevent uture breaks. Te first step may be as simple as reaching out or help. Physical therapists, occupational therapists, and support groups can assist you. In addition, this section offers more inormation on how to mend your bones. Meanwhile, getting enough calcium and vitamin D, perorming weight-bearing exercises regularly, taking steps to prevent alls, and using an osteoporosis
Living with vertebral fractures Spinal ractures, which ofen take two to our months to heal, can be very painul. Te most common way to treat pain is with over-the-counter medications such as aspirin, acetaminophen (ylenol), ibuproen (Advil, Motrin), or naproxen (Aleve, Naprosyn). Sometimes doctors prescribe stronger medications or pain, such as short-term narcotics. But be careul, as these medications may cause drowsiness, conusion, and a drop in blood pressure—all o which increase your chances o alling. Another staple o treatment is bed rest, although it should be short-term because prolonged inactivity
medication can help guard your bones against uture ractures.
can lead to urther bone loss. Your doctor may also recommend that you use ice or heat packs to ease
B
Easing the strain with a cane For something so low-tech and simple in design, a cane performs complex functions. You You hold the cane in the hand opposite the side that needs support, about four inches to the side of your stronger leg. This redistributes weight to improve stability, stability, helps reduce demand on muscles that may be weak, and takes the load off weight-bearing structures such as the hip, knee, and spine.
Standard canes. These are low-tech, lightweight, and generally inexpensive. They usually come with a curved or T-shaped T-shaped handle and a rubbercapped tip at the bottom. Many people find that
A cane can helphave you maintain mobility and ward offasfurther disability if you one or more fractures, as well assist in recovery after surgery. surgery. So don’t let self-consciousness stop you from using a cane if your doctor recommends that you try one.
a T-shaped handle is more comfortable than a curved one. A standard Standard Offset Quad model is good for people cane cane cane who need help with balance but don’t need the cane to bear a lot of weight.
A physical therapist or other clinician can help you select a cane, check that it’s the proper height, and show you how to use it. He or she may also suggest certain muscle-strengthening exercises before you start walking with your cane. Canes are available at medical supply stores and pharmacies, through specialty catalogs, and on the Internet. They generally come in standard, offset, and multiple-legged versions. Government or private insurance usually covers the cost of a basic cane if you have a written prescription from your doctor.
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canes. The The upper shaft of an offset cane bends Offset canes. outward, and the handle grip is usually flat—often a good choice for people whose hands are weak or who need a cane that bears more weight than the standard type. canes. Multiple legs offer considerable support and Quad canes. Multiple allow the cane to stand on its own when not in use. One drawback to using such a cane is that for maximum support, you must plant all the legs solidly on the ground. Doing so takes time and can slow the pace of walking.
Osteoporosis
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pain. Massage, acupuncture, bioeedback, bioeedback, and the use o a lumbar corset or back brace may also help or certain ractures. I these interventions do not help (or help enough), there are two t wo surgical procedures procedures—vertebro —vertebroplasty plasty and
kyphoplasty (see below)—that may reduce your pain, though both have potential side effects. However you ultimately treat the pain, you will also likely find it useul to make some liestyle adjustments. You may want to enlist your physical
Vertebroplasty and kyphoplasty
T
wo procedures are available to stabilize compressed vertebrae, alleviate the pain associated with this type of fracture, and improve daily functioning: vertebroplasty and kyphoplasty. These interventions are geared toward patients who haven’t responded to traditional measures such as bed rest and pain medications. In addition, kyphoplasty may restore some of the height lost when a cracked vertebra gets compressed, or at least prevent it from getting worse. Vertebroplasty is an outpatient procedure that takes less than an hour. hour. After the patient is given mild sedation, the physician inserts a needle into the affected vertebra, using an x-ray as a guide. Then bone cement is injected into the compressed vertebra, filling the holes and crevices. cre vices. The cement hardens in about 15 to 20 minutes, stabilizing the vertebra, creating a support that helps prevent any further furthe r collapse, and (ideally) alleviating pain. Kyphoplasty Kyphoplasty (see (see Figure 11, at right) is a refinement of vertebroplasty. Like Like vertebroplasty,, this procedure is aimed vertebroplasty at stabilizing compressed vertebrae and relieving pain. Also like vertebroplasty, kyphoplasty takes less than an hour, although it may require an overnight hospital stay. In this procedure, the
and improve function compared with lifestyle changes and pain medications. However,, a lack of good comparative However studies makes it hard to definitively de finitively determine which therapy is preferable. Although uncommon, the potential complications of vertebroplasty and kyphoplasty include bleeding, infection, and nerve damage. Occasionally Occasionally bone cement leaks from the treated area. If the cement enters the bloodstream or spinal canal, serious problems can
occur.. In addition, there is an increased occur fracture risk in the vertebrae adjacent to the one treated. The The FDA has also warned that soft tissue damage, nerve root pain and compression, c ompression, pulmonary embolism (blood clot in the lung), and respiratory and cardiac failure have been reported among some patients undergoing vertebroplasty or kyphoplasty. kyphoplasty. Given the uncertainties, it’s it’s important to find a physician who is experienced with the procedure and is willing to engage in a frank conversation about the risks. You You may want to ask your doctor what type of cement will be used, whether it is currently FDA-approved for the procedure, and what experience your doctor has had with the product and the procedure in general.
Figure 11: Repairin Repairing g a compressed vertebra
physician administers a mild sedative and then inserts a small tube-like instrument into the affected vertebra, using a special viewing device called a fluoroscope as a guide. Once the instrument is correctly placed, a balloon is inflated, creating a cavity in the bone. The The balloon is then deflated, and the physician injects surgical cement into the void. The creation of this hollow minimizes the risk of the cement leaking and pushes the vertebral endplates apart, restoring some height.
Kyphoplasty treats the pain associated with vertebral compressions. This technique restores some of the height of the treated vertebra.
Do these approaches work? Reviews
First, a tube is inserted into the vertebra (A (A). Then Then a balloon at the end is inflated
of studies suggest that both vertebroplasty and kyphoplasty reduce pain
and hollow in the bone (B). Finally, (B surgical cement is injected into deflated, the cavity,leaving shoringa up the vertebral endplates. endplates .
Osteoporosis
A
B
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therapist’s help in selecting a cane or walker, i you Living with a hip fracture need one. He or she can assess your needs and help Afer a hip racture, proper rehabilitation can make you choose the one that best suits your purpose (see the difference between returning to active lie and requiring long-term care. I the hip racture doesn’t “Easing the strain with a cane,” page 49). Exercise regularly, too. alk with your orthopedist heal properly, you may become limited in your ability or the physician overseeing your care about what to walk and unction in an independent manner. Both exercises are sae or you at each stage o recovery. physical and occupational therapy can be very helpul. Physical therapists can teach you exercises to Ultimately, your routine should include weightbearing exercise, which can build bone, and balance strengthen your hips, improve your coordination and flexibility exercises, which can make uture alls and balance, and increase your flexibility. A home visit with a physical therapist may help you you transition less likely. You may find that you also need to make a ew rom a hospital or rehab acility to a suitable at-home practical changes around your house that will make exercise program that can get you up and moving it easier or you to maintain your sel-sufficiency. An again and help condition your body to reduce the occupational therapist can give you expert advice. risk o alling. Te therapist can also teach you saety For example, i you can’t reach the top shelves o measures that will lessen the likelihood o injuring cabinets any longer, he or she can suggest a number yoursel and improve your day-to-day unctioning. o solutions, rom tools to help you grasp objects to You should also schedule a home visit with an ways o reorganizing your kitchen. An assistive device occupational therapist to eliminate potential hazards called a “dressing stick” can help people with limited mobility to put on and remove clothing without bending too much. Finding clothing that its correctly may also become a concern as your body changes. I you have had several vertebral ractures, you may notice that your ribcage has moved closer to your hip bones. As a result, many women find that their garments don’t fit at the waist, while a large size is too baggy in other places. Some women solve this problem by buying maternity clothes. Te elastic panels in slacks and skirts are roomy in the ront without giving too much in the back, and the loose-fitting tops are well suited or accommodating spinal changes. Low-heeled, comortable shoes that offer adequate support are also essential. Tere are many styles o “walking shoes” that fill the bill. I you have difficulty finding shoes that fit properly, you may want to have orthotic devices—supportive insoles that affect the distribution o weight—fitted by a podiatrist. po diatrist.
in your home—such as electrical cords and loose rugs in pathways, poor lighting, or a lack o handrails or grab bars. Also, talk to your doctor about other actors that can lead to alls, such as alcohol consumption or the use o certain medications.
Support groups Osteoporosis doesn’t affect only your bones. It can leave you eeling depressed, isolated, anxious, or araid. You may worry about breaking a bone or losing your independence. Or perhaps you’re overwhelmed by pain or upset by changes in your appearance. Maybe you are discouraged because you are no longer able to perorm certain activities. A support group may help you cope with these eelings and move ahead with your recovery. alk to your doctor about finding a program, or check with your insurer, local hospital, or the National Osteoporosis Foundation (see (se e “Resources, “Resources,”” page 52 52). ).
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Resources Organizations American Academy of Orthopaedic Surgeons 9400 W. Higgins Road Rosemont, IL 60018 847-823-7186 www.aaos.org
a quarterly newsletter, The Osteoporosis Report , which reviews the latest scientific information. You can order materials online, by mail, or by telephone.
This medical association for orthopedic surgeons offers information on osteoporosis for laypeople. The website features fact sheets on such topics as keeping your bones healthy, recognizing the warning signs of osteoporosis, and preventing hip fractures.
Osteoporosis and Related Bone Diseases National Resource Center National Institutes of Health 2 AMS Circle Bethesda, MD 20892 800-624-2663 (toll-free) TTY: 202-466-4315 www.osteo.org
National Center for Injury Prevention and Control Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30329 800-232-4636 (toll-free) TTY:: 888-232-6348 (toll-free) TTY www.cdc.gov/injury
This information center is dedicated to increasing awareness of osteoporosis, Paget’s disease of the bone, osteogenesis imperfecta, and hyperparathyroidism. The center was created to provide health professionals and the general public with information about these conditions and their treatment, as well as links to other resources. You’ll find fact sheets, general information, and news about osteoporosis on the website, where you can also sign up to receive the center’s electronic newsletter.
This arm of the Centers for Disease Control and Prevention focuses on reducing accidents and their resulting injuries and deaths. The division supports fall-prevention programs, and its website includes fall-prevention fall-prevention fact sheets and tips and an
Special Health Reports
online fall-prevention tool kit for seniors. National Institute on Aging Building 31, Room 5C27 31 Center Drive, MSC 2292 Bethesda, MD 20892 800-222-2225 (toll-free) TTY:: 800-222-4225 (toll-free) TTY www.nia.nih.gov This branch of the National Institutes of Health offers reliable, free information on osteoporosis for physicians and consumers. Publications are available on the website, or you can order them by mail or telephone.
National Osteoporosis Foundation 251 18th St. S., Suite 630 Arlington, VA 22202 800-231-4222 (toll-free) www.nof.org This nonprofit organization supports research on osteoporosis and develops educational programs and materials. Much of its material is also available in Spanish. Membership benefits include
Better Balance: Easy exercises to improve stability and prevent falls Suzanne Salamon, M.D., and Brad Manor, Manor, Ph.D., Medical Editors Josie Gardiner and Joy Prouty, Master TTrainers rainers (Harvard Medical School, 2014) If you have osteoporosis, it’s important to avoid falls. This Harvard Special Health Report helps you learn how to do that by improving your balance and mobility, with safe, effective balance exercises that also increase flexibility, sharpen reflexes, increase muscle strength and speed, and firm your core. Order online at www.health.harvard.edu or www.health.harvard.edu or by calling 877-649-9457 (toll-free).
Strength and Power Training: Training: A guide for older adults Elizabeth Pegg Frates, M.D., with Michele Stanten, Fitness Consultant (Harvard Medical School, 2015) Strength training can help prevent bone loss. It can also protect vitality, make everyday tasks more manageable, and help you maintain a healthy weight. This Harvard Special Health Report includes two complete workouts, plus stretches and suggestions for varying your routine. Order online at www.health.harvard.edu www.health.harvard.edu or by calling 877-649-9457 877-649-9457 (toll-free).
52 Osteoporosis
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Glossary bisphosphonates: A class of compounds that slow bone resorption. These medications are used to prevent and treat osteoporosis. bone mass: The total amount of bone tissue in the body. bone density (bone mineral density): The amount of mineralized bone tissue in a given area, usually calculated in grams per square centimeter. calcium: A mineral that is the primary component of hydroxyapatite in bone. It is also vital to many physical processes, including heart rate, blood pressure, muscle contractions, the transmission of nerve signals, and the regulation of internal organs. compact bone: Very dense bone tissue that forms the outer shell of bones and constitutes a large part of the long bones of the arms, legs, and ribs. Also called cortical bone. compression fracture: The collapse of a bone, most often a vertebra. dorsal kyphosis: An abnormal front-to-back curvature of the mid-to-upper mid-to-up per spine that can result from compression fractures of vertebrae. Sometimes called dowager’s hump.
osteoblasts: Bone-forming cells. osteoclasts: Bone-removing cells. osteocytes: Osteoblasts that have completed their bone-forming function and have become trapped in new bone tissue, evolving into structural bone cells. osteons: The basic units of compact bone, each consisting of tightly packed concentric rings of tissue with a blood vessel running through the central channel. parathyroid hormone (PTH): A hormone that regulates calcium levels. It prevents the level of blood calcium from going too low by stimulating the breakdown of bone. In addition to triggering bone loss, it can stimulate bone formation. Given appropriately, it can increase bone mass, and a synthetic form is used as a treatment for osteoporosis. peak bone mass: The greatest amount of bone tissue that a person has during his or her life; typically reached by age 30. primary osteoporosis: Bone loss that doesn’t result from an identifiable pathological process.
dual energy x-ray absorptiometry (DEXA or DXA): A test in which x-rays are used to measure bone density and produce an image of the bone; the preferred screening test for osteoporosis.
remodeling: The body’s mechanism for systematically removing old bone tissue and replacing it with new bone to preserve the strength of the skeleton.
femoral neck: The fracture-prone top portion of the femur, or thighbone, just below the hip joint.
resorption: The removal of bone tissue—both protein and minerals—by osteoclasts.
glucocorticoids: A class of hormones produced by the adrenal gland and simulated by medications such as prednisone. These medications can contribute to osteoporosis.
secondary osteoporosis: Bone loss associated with an identifiable medical condition or treatment with certain drugs.
hormone therapy: Augmentation of a woman’s depleted hormones with estrogen alone or a combination of estrogen and progestin or progesterone; sometimes used to reduce osteoporosis risk in postmenopausal women. hydroxyapatite: The mature, hard, somewhat crystalline mineral compounds in bone tissue. hyperparathyroidism: A condition in which the body produces excessive amounts of parathyroid hormone, disrupting the regulation of calcium. As a result, calcium is taken from the bones, blood levels of calcium rise, and increased amounts of calcium may be excreted in urine.
total hip: A term used in bone scanning to refer to a specific area in the hip, near the hip joint. trabecular bone: Bone tissue arranged in a meshwork of thin plates or beams that is commonly found at the center of long bones and that constitutes a large part of the hip and vertebrae. Also called cancellous bone or spongy bone. vertebral fracture assessment: A scan of the spine to look for deformities in the vertebrae. These deformities may indicate fractures.
vitamin D: A hormone that plays a key role in ensuring the absorption of calcium from the intestines.
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Osteoporosis
This Harvard Health Publication was prepared exclusively for Fred Hirshberg - Purchased at https://www.health.harvard.edu
53
54 Osteoporosis
www.health.harvard.edu
This Harvard Health Publication was prepared exclusively for Fred Hirshberg - Purchased at https://www.health.harvard.edu
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