minding your bones

Osteoporosis refers to a decrease in bone density, causing bones to weaken and more likely to   fracture. Most people reach their peak bone mass by their early 20s, after which, bone mass is lost more quickly than it’s created.

Since osteoporosis often has no symptoms and is considered a silent disease (until a fracture occurs after a sudden strain or a fall), it can go untreated for years, leaving the bones increasingly brittle over time. Areas most likely to be affected include the spine/vertebrae, hip and forearm.

This disorder generally affects the older population, particularly post-menopausal women and older men. According to the federal Office of Disease Prevention and Health Promotion, an estimated 10 million people in the U.S. over age 50 have osteoporosis. Most are women, though men account for about 20% of the total. Moreover, roughly one out of two women will sustain a bone fracture during their lifetime due to osteoporosis. Research also has shown the risk of mortality after a hip fracture is as high as 50%.

Risk Factors
There are both non-modifiable and modifiable risk factors for osteoporosis.

Non-modifiable factors:
* Age: everyone loses bone mass with age.
* Gender: women are at higher risk, predominantly after menopause.
* Race: osteoporosis is more common in people of Caucasian and Asian descent.
* Family history: having a sibling or parent with osteoporosis increases a person’s risk.

Modifiable risk factors:
* Lowered sex hormone levels: which weakens the bone.
* Other hormone problems: such as thyroid disease and adrenal gland problems.
* Medical conditions: rheumatoid arthritis, kidney disease, celiac disease and cancer, among others.
* Lifestyle choices: cigarette smoking or drinking too much alcohol, not exercising regularly or being inactive.
* Medications: steroids, anti-seizure drugs, acid reflux medications, and some prescriptions that treat cancer.
* Dietary factors: people with low calcium intake, a history of eating disorders and/or bariatric surgery, and/or a history of vitamin D deficiency.

Diagnosing Osteoporosis
A bone density test (DXA) is utilized to identify potential osteoporotic risks. The general recommendation is for women to have a screening DXA at age 65. However, women with increased risk factors (listed above) or who have gone through menopause early (younger than age 45) should get a baseline DXA earlier, on the recommendation of a primary care physician or gynecologist.

For men with a history of low testosterone or of previous fractures (or the listed risks), a baseline DXA is also indicated.

While there is no cure, there are many measures to help prevent osteoporosis, as well as to treat it:

* Eliminate the modifiable risk factors.
* Engage in weight resistance/weight training exercises: 30 minutes, five days a week, of exercises such as walking, climbing stairs, yoga, and Tai Chi.
* Work with a physical therapist who can help with flexibility and balance to reduce the chances of falling.
* Optimize calcium and vitamin D in the diet or through supplements, with a per-day calcium intake of 1,200 mg. The preferred calcium intake is through diet, but can be supplemented with calcium carbonate or calcium citrate.
* Undergo pharmacologic therapy, which includes five classes of medications:
(1) Bisphosphonates, which include the pills alendronate/Fosamax (taken once a week), risedronate/Actonel (once a week or monthly) and ibandronate/Boniva (monthly). Also included is zoledronic acid/Reclast, an annual IV infusion.
(2) Prolia, an injection once every six months under the skin.
(3) Initial “bone builders” like teriparatide/Forteo or abaloparatide/Tymlos.
(4) Secondary bone builders such as romosozumab/Evenity.
(5) Raloxifene/Evista for treating post-menopausal women.
(“Bone Builders” are typically reserved for severe osteoporosis: for patients who already have sustained a fracture or did not respond or progress using other treatments.)

Your doctor will discuss treatment modalities and potential side effects with you, and recommend the best approach to your specific risk factors and osteoporosis severity. I urge all patients to be proactive when it comes to an osteoporosis screening–and to bring it up at your next annual physical exam.

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