What are the chances of preventing osteoporosis?

Heinz Redwood
October 30, 2000 (Reviewed: February 2, 2003)

Introduction

For osteoporosis, prevention is the key. Unlike many other diseases, where prevention is either difficult to achieve or demands enormous willpower and self-denial in changing your lifestyle, preventing osteoporosis is relatively straightforward if you start in good time. Treatment of the disease is feasible but more problematic than prevention. For the present, there is no cure. All the more reason to make a real effort to prevent it.

What is osteoporosis?

Literally, 'porous bone'. Bone density decreases if bone cells are destroyed faster than they are replaced by natural processes. Eventually, this will allow bones to break very easily. The most frequent fractures caused by osteoporosis are those of the spine, the hip and the wrist.

There are two main kinds of 'primary' osteoporosis:

• Type 1 - Post-menopausal in women, caused by oestrogen deficiency.
• Type 2 - Age-related, mainly among women and men over the age of 70.

There are also 'secondary' forms of the disease, arising from (for example) long-term use of corticosteroid drugs, kidney failure, cystic fibrosis, or advanced cancers.
Prevention has a good chance of success, especially when aimed at the primary forms of the disease, which are also the most common.

How widespread is osteoporosis?

In the USA, the National Osteoporosis Foundation estimates that 10 million people have osteoporosis (8 million women and 2 million men) and a further 18 million are at risk because their bone density is low. It is these 18 million who would draw real benefit from preventive measures that would stop their bone density from falling further and would often help it to
recover towards normal levels.

In France, approximately 2 million post-menopausal women have osteoporosis . Related to the size of population, this suggests that the prevalence of osteoporosis in Europe is similar to that in the USA.

Osteoporosis is rare under the age of 50 but rises with age or, for women, after the menopause.
At present, osteoporosis is mainly a problem in the industrialised world, but it will gradually spread to those Less Developed Countries where longevity is rising. The World Health Organisation has estimated that there were 1.7 million hip fractures worldwide in 1990; this figure will rise to 6 million by 2050, when three-quarters of all such fractures will occur in today's Less Developed Countries.

"Hip fractures account for most of the morbidity, mortality and costs of the disease" because, of those patients who were coping independently before, "only about half are able to live independently after the fracture" (WHO ).

The mean age of women with hip fractures is 80, compared with 65 for spinal [vertebral] fractures. The fact that osteoporosis is four times more common in women than in men is partly the result of oestrogen loss at the menopause, and partly age-related; women live longer than men.

The medical cost of osteoporosis

In the USA, the direct medical cost of treating fractures caused by osteoporosis has been estimated as $13.8 billion in 1995, of which nearly two-thirds was the cost of hospitalisation and 28% nursing home costs (Ray , 1997). Put more simply, osteoporosis fractures cost America $38 million every day, and that cost will have risen steadily since 1995.

It is a colossal price to pay for a disease that is basically preventable.

American estimates put osteoporosis-related fractures at around 1.5 million in 1995:

700,000 spinal fractures
300,000 hip fractures
250,000 wrist fractures
300,000 others

These fractures were responsible for 432,000 hospital admissions, 180,000 nursing home admissions, and 2,500,000 physician visits (National Osteoporosis Foundation ).

Nearly two-thirds of total direct costs of the disease (or about $ 8.7 billion) were attributable to hip fractures because of the gravity of their consequences in the longer term, especially the frequent loss of personal independence and hence the need for residential nursing home care.

Risk factors

An understanding of who is at risk of osteoporosis and the fractures caused by the disease is fundamental to any approach to prevention. Among the more important risk factors are:

Female gender after the menopause
Thin, small body frame
A reduced number of menstrual periods before the menopause
Low testosterone levels in men
Family history of osteoporosis
Anorexia nervosa/bulimia
Low calcium content of diet
Inactive lifestyle
Cigarette smoking
Heavy alcohol consumption
Long term medication with corticosteroids or anticonvulsants

(Source: National Osteoporosis Foundation website)

Such a list does not mean that if these factors apply to you, you will get the disease. For example, "female gender after the menopause" does not imply that most post-menopausal women will succumb to osteoporosis. All it means is that, statistically, the risk is greater than that before the menopause, or the risk for a man of corresponding age with normal testosterone levels.

Risk factors are analysed in order to alert you and your physician to the possibility of developing osteoporosis later in life, especially if you tick many of these factors as applicable to you. Another review of risk factors indicates that the highest relative risk of bone fracture exists when five or more of the following conditions co-exist:

Age over 80
Mother had a hip fracture
Any fracture after the age of 50
Fair to poor health
Previous hyperthyroidism (overactive thyroid gland)
Use of anticonvulsants
Use of long-acting benzodiazepines
Weight or height less than at age 25
More than two cups of coffee per day
Standing less than 4 hours per day
No walking as exercise
Unable to rise from sitting position
Defective eyesight (depth perception, contrast sensitivity)
Pulse rate higher than 80 per minute

(Source: Ullom-Minnich , 1999)

The purpose of risk factor analysis in these terms is not to scare you but to promote awareness and successful prevention.

The first hurdle: awareness

In May 2000, the National Osteoporosis Foundation in the USA published the results of a Gallup Survey of 1,039 women with osteoporosis .

Of these, only 33% said that they had taken preventive steps before being diagnosed with osteoporosis. The main preventive measure had been to take calcium supplements with their diet.

Nearly half the sample believed that "osteoporosis is an unavoidable part of aging for women": this is not true.

Nearly half were unaware of the existence of preventive medication.
86% of the interviewees had never talked to their doctor about preventing osteoporosis before it was diagnosed.

Evidently, there is a serious lack of awareness about the risk of developing osteoporosis. This is aggravated by the fact that many women regard the disease as inevitable in later years and are not aware of preventive steps nor inclined to raise the subject with their physician. Promoting awareness is the first necessary pre-condition for mobilising prevention.

Prevention: what can you and your doctor do?

There are three main tasks:

1 - Screening by the doctor
2 - Lifestyle changes by the patient before osteoporosis sets in
3 - Preventive medication, prescribed by the doctor, taken by the patient.

If osteoporosis develops in spite of these steps, then more intensive treatment accompanied by more radical lifestyle changes must follow. The main objective of prevention is to avoid the necessity for these. What the women with osteoporosis who were interviewed by Gallup fear most is broken bones, inability to perform daily tasks, losing their independence, cutting back on activities with their family and friends, and residential care in nursing homes. Prevention is the effort to lay these very real fears about osteoporosis to rest while that is still possible.

Screening

The measurement of bone mineral density [BMD] is a widely accepted indicator today. Low and falling BMD is normally a sign of developing osteoporosis, although expert opinions still differ on whether the correlation between the two is always reliable. However, the National Osteoporosis Foundation in the USA advises densitometric screening for all women over the age of 65. Today, that is far from being achieved.

In the USA, "insurance coverage (or lack thereof) of BMD testing could significantly limit implementation of the NOF recommendations. Medicare reimburses for BMD testing, but most private insurers do not" (Heinemann , 2000).

In the UK, where treatment under the National Health Service is free of charge, a national survey of doctors has revealed that, although BMD testing has increased materially during the last five years, only "36% of GPs* stated that they now had direct access to bone densitometry... 45% reported that they could only gain access by means of consultant referral" (Rowe , 1999). [* general practitioners or family physicians]

Preventive life style changes

Risk factors (see above) include those which are part of you (age, gender, family history) and those which relate to your habits and lifestyle. There is nothing much that you can do about the former, but a great deal that can be done to change habits and lifestyle as a preventive measure. Basically, these changes are of three kinds: eating and drinking habits, exercise, and direct precautions to avoid bone fractures such as falls.

Adequate intake of calcium and Vitamin D (if necessary in the form of supplements), no smoking and less coffee and alcohol are the main elements in reducing dietary risk factors. For practical details, see " How to Avoid Osteoporosis"

Exercise is important, and it must be of the weight-bearing type (for example, gymnastics, running, dancing, walking and stair climbing, but not swimming or cycling). The extent to which weight-bearing exercise can actually increase bone density is uncertain and opinions differ. On the other hand, preventing loss of bone density by means of exercise is widely accepted as desirable and effective. Gymnastics, in particular, can be adapted to the needs and capabilities of older age groups and will be of benefit even to those who are bedridden.

Useful and inexpensive as a form of self-help, the problem with exercise as a preventive measure is how we can convince ourselves to do it regularly and long enough every day. Less difficult than smoking cessation or dieting to lose weight, exercise nevertheless needs persistence and time - even when you are "too busy". It is not enough to exercise occasionally.

Preventive medication

The role of preventive medication is now well recognised as a helpful - sometimes indispensable - way of forestalling osteoporosis, but it is not without problems. Contrary to the dictates of public policy in most countries, medication is not a matter of one-size-fits-all. It needs to be adapted to the needs and medical status of each individual patient. For preventive medication, this is even more important than for drug treatment of actual disease, because the patient is not driven by tangible symptoms to take drugs. Preventive medication is, and must remain, optional at the discretion of the patient in consultation with the physician.

This optional element is particularly relevant to Hormone Replacement Therapy [HRT], which is of proven benefit in remedying oestrogen deficiency in women after the menopause. It is recommended for the prevention "of postmenopausal osteoporosis but it needs to be continued for at least 5-10 years to be beneficial" (British National Formulary , 2000). Against this proven benefit there exists a relatively small increase in the risk of developing breast cancer.

"40% of women discontinue HRT within 8 months of initial therapy or never fill the prescription" (Cutson & Meuleman , 2000).

Some discontinue because of side effects, but the fear of breast cancer makes many women reluctant to persist with HRT. That risk is low, but increases slightly with the duration of HRT treatment. A woman's decision whether or not to take and persist with HRT is evidently a matter of personal choice and personal attitude towards (low) risk.

Alternative forms of preventive medication include calcium and Vitamin D. It is a moot point whether these are dietary supplements (see above) or 'medication'.

Important advances in preventive medication have been achieved in recent years with the bisphosphonate drugs (of which alendronate [Fosamax] was the first) and oestrogen-like agents which avoid breast and uterus actions - e.g. raloxifene (Evista). Both types have been approved by the Food and Drug Administration in the USA for the prevention as well as treatment of osteoporosis. In some countries, like the UK, calcitonin (Miacalcic) "may be considered for those at high risk of osteoporosis for whom HRT is unsuitable" (BNF, see reference 11).

For those who need and are willing to take preventive medication, the questions of cost and 'Who Pays?' may present obstacles. As already observed for BMD screening (see above), insurance cover can be a problem in the USA, whilst public sector health care in Europe may restrict reimbursement of costly drugs, demand proof of cost-effectiveness, and ration or otherwise limit prescribing to certain types of patient, in order to contain cost. Preventive medication is particularly vulnerable to this, because the patient is not actually ill.

Policy makers and health insurers need to accept the concept of preventive medication for chronic diseases like osteoporosis. The preventive use of vaccines for many infectious diseases is universally recognised as appropriate and effective. In our ageing society, that concept needs to be extended to areas like osteoporosis, where preventive medication, in spite of its cost, will be much cheaper than treatment after you have succumbed to the disease.

The use of hormone replacement therapy must be reconsidered in the light of recent findings from the Women's Health Initiative Study. The potential risk of breast cancer and other side effects has been determined fairly conclusively - see "Hormone Replacement Therapy (HRT) - Now What to Do?" (Robert Griffith, editor)

Source

• Preventing osteoporosis is more successful than treating it. H. Redwood, The Merck Manual of Medical Information, Home Edition., 1997

Footnotes
1. National Osteoporosis Foundation, http://www.nof.org/osteoporosis/stats.htm, Stand Oktober 2000
2. "La prévention du vieillissement pathologique" G. Kaltenbach, Le Concours Médical, 2000
3. "Interim Report and Recommendations of the WHO Task Force for Osteoporosis"  World Health Organisation, Osteoporosis International, 1999, vol. 10, pp. 259--264
4. "Medical expenditure for the treatment of osteoporotic fractures in the United States in 1995" NF. Ray,  et al, J of Bone Miner. Research, 1997, vol. 12, pp. 24--35
5. Status Report: "Osteoporosis: Review of the Evidence for Prevention, Diagnosis and Treatment and Cost-Effective Analysis"  National Osteoporosis Foundation,  et al, Osteoporosis International, 1998, vol. 8
6. "Prevention of osteoporosis and fractures" P. Ullom-Minnich, American Family Physician, 1999, vol. 60, pp. 194--202
7. Gallup Survey of women with osteoporosis, for National Osteoporosis Foundation, Mai 2000
8. "Osteoporosis: An overview of the National Osteoporosis Foundation clinical practice guide" DF. Heinemann, Geriatrics, 2000, vol. 55, pp. 31--36
9. "The management of osteoporosis in general practice: Results of a national survey" R. Rowe, Osteoporosis Review, 1999, vol. 7, pp. 1--3
10. British National Formulary No. 39, "6.6 - Drugs affecting bone metabolism", p. 350, Marz 2000
11. "Managing menopause TM. Cutson, E. Meuleman, American Family Physician, 2000, vol. 61, pp. 1391--1400

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