Prevention/nutritional management of osteoporosis

Introduction

According to Mayer (2015), osteoporosis is a disease where decreased bone strength increases the risk of a broken bone. It is the most common reason for a broken bone among people who are older. Bones that commonly break include the back bones, the bones of the fore arm, and the hip. Until a broken bone occurs there are typically no symptoms.

Bones may weaken to such a degree that a break may occur with minor stress or spontaneously chronic pain and a decreased ability to carry out normal activities may occur following a broken bone. Osteoporosis may be due to lower than normal peak bone mass and greater than normal bone loss. Bone loss increases after menopause due to lower levels of estrogen. Osteoporosis may also occur due to number of diseases or treatment including alcoholism, anorexia, Hyperthyroidism, surgical removal of the ovaries and kidney disease.

Certain medications increases the rate of bone loss including some anti-seizure medication, chemotherapy, proton pump inhibitors. Osteoporosis is defined as a bone density of 2.5 standard deviation below that of a young adult this is typically measured by dual energy x-ray absorptiometry at the hip.

History of osteoporosis

The linked between age related reduction in bone density and fracture risk goes back at least to Astley Cooper, and the term “osteoporosis and recognition of its pathological appearance is generally attributed to the French pathologist Jean Lobstein. The American endocrinologist faller Albright linked osteoporosis with the postimenpausal state. Bisphosphonates were discovered in the 1990s. Anthropologists have studied skeletal remain that should loss of bone density and associated structural changes that were linked to a chronic mal-nutrition in the agricultural area in which these individual lived. It follows that the skeletal deformation may be attributed to their heavy labor in agriculture as well as to their chronic malnutrition” causing the osteoporosis seen when radiographic of the remains was made.

Risk factors of osteoporosis

Risk factors for osteoporotic fracture can be split between non modifiable and modifiable (potentially). In addition, osteoporosis is a recognized complication in specific diseases and disorder. Medication use is theoretically modifiable, although in many cases the use of medication that increases osteoporosis may be unavoidable. Caffeine is not a risk factor for osteoporosis. It is more likely for a female to get osteoporosis than a male.

Non modifiable: Bone density peaks at about 30years of age. Women lose bone mass more rapidly than men.

  • The most important risk factors for osteoporosis are advanced age (in both men and women) and female sex: estrogen deficiency following menopause or oopherectomy is correlated with a rapid reduction in bone mineral density while in men a decreased testosterone levels has a comparable (but less pronounced) effect.
  • Race: while osteoporosis occurs in people from all ethic groups European or Asian ancestry predisposes for osteoporosis.
  • Heredity: those with a formally history of fracture or osteoporosis are at an increased risk, the heritability of the fracture, as well as low bone mineral density, is relatively high, ranging from 25 to 800. At least 30 genes are associated with the development of osteoporosis.
  • Those who have already had a fracture are at least twice as likely to have another fracture compared to someone of the source age and sex. Early menopause / hysterectomy is another predisposing factor.

Potentially modifiable

  • Excess consumption of alcohol: Although small amount of alcohol are probably beneficial (bone density increases with increasing alcohol intake), chronic heavy drinking (alcohol intake greater than three units/day) probably increase fracture risk despite any beneficial effects on bone density.
  • Vitamin D deficiency: Low circulatory vitamin D is common among the elderly worldwide. Vitamin D insufficiently is associated with increases parathyroid hormone (PTH) production PTH increases bone reabsorption, leading to bone loss. A positive association exists between serum 1, 25 dehydroxy cholecalaperal levels and bone mineral density. While PTH is negatively associated with bone mineral density.
  • Tobacco smoking: Many studies have associated smoking with decreased bone health, but the mechanisms are unclear. Tobacco smoking has been proposed to inhibit the activity of osteoblasts and is an independent risk factor for osteoporosis smoking also results in increased break down of exogenous estrogen, lower body weight and earlier menopause all of which contribute to lower bone mineral density.
  • Malnutrition: Nutrition has an important and complex role in maintenance of good bone. Indentified risk factors include low dietary calcium and / or phosphorus, magnesium, zinc, boron, iron, fluoride, copper, vitamin A, K, E and C ( and D) where skin exposure to sunlight provides an inadequate supply). Excess sodium is a risk factor. High blood acidity may be diet-related, and is known as antagonist of bone. Some have identified low protein intake as associated with lower peak bone mass during adolescence and lower bone mineral density in elderly populations. Conversely, some have identified low protein intake as a positive factor, protein is among the causes of dietary acidity. Imbalance of omega-6 to omega -3 polyunsaturated fats is yet another identified risk factor.
  • High dietary protein from amino sources: Researchers have found an association between diets high in animal protein and increased urinary calcium and have been linked to an increase in fractures. However, the relevance of this observation to bone density is unclear since higher protein diets tend to increases absorption of calcium from the diet and are associated with higher bone density. Indeed, it has recently been argued that low protein diets cause poor bone health. No intervention that have been performed on dietary protein in the prevention and treatment of osteoporosis.
  •  Underweight/inactive: Some bone remodeling occurs in response to physical stress, so physical inactivity can lead to significant bone loss. Weight bearing exercise can increase peak bone mass achieved in adolescence and a highly significant correlation between bone strength and muscle strength has been determined. The incidence of osteoporosis lower in over–weight people.
  • Heavy metals: A strong association between cadmium and lead with bone disease has been established low-level exposure to cadmium is associated with an increased loss of bone mineral density readily in both genders, leading to pain and increased risk of fractures especially in the elderly and in females. Higher cadmium exposure results in osteomalacia (softening of the bone)

Signs and symptoms of osteoporosis

Osteoporosis itself has no symptoms. Its main consequence is the increased risk of bone fractures. Osteoporotic fractures occur in situation where healthy people would not normally break bones. They are therefore regarded as fragility fractures. Typical fragility fractures occur in the vertebral column, rib, hip and wrist.

  • Fracture: Fractures are the most dangerous aspect of osteoporosis. Debilitating acute and chronic pain in the elderly is often attributed to fractures from osteoporosis and can leads to further disability and early mortality. These fractures may also be asymptomatic. The most common osteoporotic fractures are of the wrist, spine, shoulder and hip. The symptoms of a vertebral collapse (compression fracture) are sudden back pain, often with radicular pain (shooting pain due to nerve root compression) and rarely with spinal cord compression. Multiple vertebral fractures lead to a stooped posture, loss of height and chronic pain with resulted reduction in mobility. Fracture of the long bone acutely impair mobility and may require surgery. Hip fracture, in particular, usually requires prompt surgery, as serious risk are associated with it, such as deep vein thrombosis and pulmonary embolism and increased mortality. The term “established osteoporosis” is used when a broken bone due to osteoporosis has occurred. Osteoporosis is a part of frailty syndrome.
  • Fall risk: The increased risk of falling associated with aging leads to fracture of the wrist, spine and hip. The risk of falling in turn is increased by impaired eyesight due to any cause (e.g. glaucoma, ivacular degeneration) balance disorder, movement disorder (e.g. parkinson’s disease), dementia and sarcopenia (age related loss of skeletal muscle). Collapse (transient loss of postural tone with or without loss of consciousness) lead to significant risk of falls, cause of syncope are manifold but may include cardiac arrhymias (irregular heart beat), vasovagal syncope, orthostatic hypotension (abnormal drop in blood pressure on standing up) and seizures. Removal of obstacles and loose carpets in the living environment may substantially reduce falls. Those with previous falls, as well as those with balance disorder are most at risk.

Diagnosis of osteoporosis

Multiple osteoporotic wedge fractures demonstrated on a lateral theraco – lumber spine x-ray. The diagnosis of osteoporosis can be made conventional radiography and by measuring the bone mineral density (BMD). The most popular method of measuring BMD is dual-energy x-ray absorptiometry. In addition to the detection of abnormal potentially modifiable underlying causes. This may be done by blood tests. Conventional radiography: conventional radiography is useful, both by itself and in conduction with CT or MRI for detecting complications of osteopenia (reduce bone mass, pre osteoporosis), such as fractures for differential diagnosis of osteopenia or for follow up examinations in specific clinical settings such as soft tissue calcifications secondary hyperparathyroidism, or osteomalacia in renal osteodystrophy.

Dual-energy x-ray: Dual energy x ray absorptiometry (DXA) is considered the gold standard for the diagnosis of osteoporosis. Osteoporosis is diagnosed when the bone mineral density is less than or equal to 25 standard deviations below that of a young (30 – 40 years old, healthy adult women reference population. This is translated as a T score. But because bone density decreases with age, the world health organization has established the following diagnostic guide lines.

Category T- score range % young women
Normal T – score ≥ – 1.0 85 %
Osteopenia -2.5 ≤ T – score ≤ – 10 14 %
Osteoporosis T- score ≤ 2.5 with fragility fracture 0.6 %

The international society for clinical densitometry takes the position that a diagnosis of osteoporosis in men under 50 years of age should not be made on the basis of densitometry criteria alone. It also states, for premenopausal women, z–scores (comparison with age group rather than peak bone mass) rather than T-scores should be used and the diagnosis of osteoporosis in such women also should be made on the basis of densitometry criteria alone.

Prevention of osteoporosis

According to WHO (2003) life style prevention of osteoporosis is in many aspects the inverse of the potentially modifiable risk factors. As tobacco smoking and high alcohol intake have been linked with osteoporosis smoking cessation and moderation of alcohol intake are commonly recommended as ways to help prevent it. Inclusion of calcium and vitamin D in meals to build up healthy bone is also a major preventive measure to osteoporosis. In many cases are linked to deficiency in calcium and vitamin D.

Nutritional management of osteoporosis

Calcium and vitamin D have been known as a good nutritional management for osteoporosis. Calcium is needed for our heart, muscle and nerve to function properly and for blood clot. Inadequate calcium significantly contributes to the development of osteoporosis. Many published studied show that low calcium intake through out life is associated with low bone mass and high fracture rates. National nutrition surveys have shown that most people are not getting the calcium they need to grow and maintain healthy bones. To find out how much calcium you need, see the recommended calcium intakes (in milligrams) chart below.

Life Stage Groups mg/day
Infant 0 to 6 months 200
Infant 6 to 12 months 260
1 to 3 years old 700
4 to 8 years old 1,000
9 to 13 years old 1,300
14 to 18 years old 1,300
19 to 30 years old 1,000
31 to 50 years old 1,000
51 to 70 years old males 1,000
51 to 70 years old females 1,200
70 years old 1,200
14 to 18 years old, pregnant / lactating 1,300
19 to 50  years old pregnant / lactating 1,000

(Source: Food and Nutrition Board, Institute of Medicine, Natural Academy of Sciences, 2010).

The body needs vitamin D one can’t from enough of the hormone calcitnol (known as the ‘active vitamin D”). This in turn leads to insufficient calcium absorption from the diet. In this situation, the body must take calcium from its stores in the skeleton, which weaken existing bone and prevent the formation of strong. New bones, you can get vitamin D in three ways through the skin, from the diet and from supplements. Expert recommend on daily intake of 600 IU (international units ) of vitamins D up to age 70. Men and women over age 70 should increase their uptake to 800 IU daily, which also can be obtained from supplements or vitamin D rich foods such as egg yolks, saltwater fish, liver and fortified milk.

The Institute of Medicine recommends not more than 4,000 IU per day for adults however, sometimes doctors prescribe higher doses for people who are deficient in vitamin D. other management approach is the modification of a person’s life style E.g. weight – bearing endurance exercise and / or exercises to strengthen muscles improve bone strength in those with osteoporosis and use of medications in decreasing the risk of future fractures in those who have already sustained a fracture due to osteoporosis.

Conclusion

Osteoporosis is a disease in which decreased bone strength increase the risk of a broken bone. This could be as a result of deficiency in calcium and vitamin D nutrients. Although other factors surround the occurrence of osteoporosis. It is mostly related with the deficiency in nutrients. This could be prevented by a simple inclusion of calcium and vitamin D in our meals.

References

Golob, A. L. (2015). Osteoporosis: Screening, prevention and management. The Medical Clinic of North America, 99, 7-9.

Handa, R., Kalla, A. & Maalouf, G. (2008). Osteoporosis in developing countries: Best practice and research. Clinical Rheumatology, 22: 67-71

Moyer, V.A. (2013). Vitamin D and calcium supplementation to prevent fractures in adult: U.S. preventive services task force recommendation statement. Annals of Internal Medicine, 158,26-9.

Nelson, H.D., Haney, E.M., Chou, R. Dana, T., Fu, R. & Bougatsos, C. (2010). Screening for osteoporosis: Systematic review to update of 2002 U.S. preventive services task force recommendation. Agency for Healthcare Research and Quality, 56(1),13-21.

Walls, G.A., Cranney, A., Peterson, J. Boucher, M. Shea, B. Robinnson, V. Coyle, D. & Tugwell, P. (2008). Etidronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database of Systematic Reviews, 7, 118-126.

WHO (2003). Prevention and management of osteoporosis: A report of the WHO Scientific Group. Geneva: World Health Organisation.  

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