Osteoporosis is characterized by a loss of bone strength, which increases the risk of fractures. In most cases, the bones become brittle due to a lack of calcium, phosphorus, and other minerals. Osteoporosis makes the bones more porous and increases the likelihood of a fracture in an ordinary fall that would not normally occur.
NB: Osteoporosis is not a disease, but a natural, age-related process.
Who is affected by osteoporosis?
Osteoporosis is most common in people over the age of 65, but it can occur earlier. It is estimated that 1 in 4 women and 1 in 8 men will develop osteoporosis during their lifetime. From the age of 50 until the end of their lives, 4 out of 10 women suffer an osteoporosis-related bone fracture. The bones of the hip, wrist, and spine are the most common osteoporosis-related fractures.
Objective: Prevent fractures
According to the new guidelines, physicians should focus on fracture prevention rather than treating osteoporosis at all costs. This new direction is based on the latest scientific evidence. Osteoporosis is only one of many risk factors for fractures. This means that even with osteoporosis the risk of fracture might still be not so high. Conversely, it is possible to have a higher risk of experiencing a fracture without osteoporosis.
Therefore, the doctor should make an overall assessment of the patient’s health, the medications that are taken, family history, lifestyle, etc. Only if he considers it necessary will he propose a bone densitometry test, which measures bone mineral density. Previously, the decision of whether or not to carry out treatment was mainly based on the results of this test.
All the data collected will be used to determine the probability of fracture occurring in the next 10 years. Several questionnaires have been developed to enable the doctor to assess this risk. These vary slightly from country to country and were tested on large samples of populations.
The diagnosis of osteoporosis can be made if one of these situations:
- An X-ray examination or bone density test
- A bone fracture
If osteoporosis is diagnosed and treated, it is possible to stabilize or improve the bone condition to such an extent that the risk of fracture is reduced by 50%.
The bone densitometry test
Bone mineral density (BMD) is the amount of the various minerals (calcium, phosphorus, etc.) that makes up the bones.
There are different techniques for measuring bone mineral density. The most common is Dual-Biphotonic X-rays Absorptiometry. This painless test exposes you to very little radiation. The result of this test (the T-score) is compared with the average bone mineral density of young adults.
It should be noted, however, that this test does not reveal the quality of the bone structure. The strength of the bone depends not only on its density but also on the quality of its structure.
Change in bone mass with age
Not all people have the same bone “capital”. Three-quarters of this capital is hereditary. Good living habits (physical exercise, calcium intake, etc.) help to maintain and grow this capital.
The peak of bone mass is reached around the age of 35. This usually lasts until the age of 40. After that, bone mass tends to decrease by 1-2% per year.
In the first 10 years after the onset of menopause, bone loss accelerates by 2-3% per year due to reduced estrogen production. The loss then stabilizes at around 1% per year.
In men, the loss is more gradual. At the age of 65, however, their risk of developing osteoporosis increases and they are more likely to have fractures.
When trying to limit or prevent bone fractures, the main goal is to avoid the consequences: pain, loss of autonomy, reduced quality of life (especially in hip fractures), etc. Between 20 and 25% of people who suffer a hip fracture will die within the next year.
The consequences are often more serious for men, who at that age tend to be in a worse state of health than women.
Symptoms and people at risk of osteoporosis
- Osteoporosis usually causes no symptoms, hence the nickname “silent thief”. Often the bone loss is only noticed after a fracture, which occurs when falling.
- One of the first symptoms is sometimes a decrease in height (by 4 cm or more). This decrease may usually be related to back pain caused by a collapsed vertebra.
- People over 65 years old.
- People who have ever suffered a collapsed vertebra or a fractured spine.
- People with a family history of osteoporosis-related bone fractures.
- Women who have entered menopause prematurely (before the age of 45) for natural reasons or after removal of the ovaries. Estrogen production, which helps to maintain bone mass, decreases significantly during menopause. The longer the body is exposed to estrogen, the lower the risk of osteoporosis. In addition, women who have estrogen deficiency due to so-called hypogonadism are also at increased risk.
- People with a disease that prevents calcium absorption in the intestines (e.g. Crohn’s disease).
- Women who have had amenorrhea (missed menstrual periods) for more than 6 months (except pregnancy).
- Individuals who have been on oral corticosteroid therapy for more than 3 months. Also, those who have taken or are taking antiepileptic drugs or heparin.
- To a lesser extent, people with rheumatoid arthritis or people who have had hyperthyroidism. These two factors are considered minor.
Risk factors for osteoporosis
The following factors increase the risk of osteoporosis. Their effect is cumulative. However, their influence is less significant than the factors described in the section on people at risk.
- Lack of physical activity
- A lifelong diet low in calcium
- Vitamin D deficiency caused by limited sunlight or a diet low in vitamin D This vitamin is essential for calcium metabolism.
- Significant weight loss (more than 10% of body weight) before the age of 25 or a weight of less than 60 kg (132 pounds).
- Excessive consumption of alcohol.
- High caffeine consumption (coffee, chocolate, cola, energy drinks) Caffeine is believed to increase calcium loss through increased urine production. Experts often recommend that older people not only ensure an adequate supply of calcium and vitamin D but also should not drink more than 3 cups of coffee per day.
Prevention of osteoporosis
The main goal is the prevention of bone fractures. Prevention reduces the risk of fractures associated with osteoporosis by half.
Care should be taken to prevent osteoporosis and fractures at an early age. As the World Health Organization (WHO) states, the earlier a healthy lifestyle is adopted, the greater the benefit.
Most experts recommend that the following individuals undergo a thorough assessment of their fracture risk by a physician, as mentioned at the beginning:
- Women and men 65 years and older
- Postmenopausal women are potentially at risk
- Men aged 50 years or older if at risk
In certain special cases, for example in the presence of rheumatoid arthritis, a screening test can be requested before the age of 50.
Basic preventive measures
The following 3 measures are the most important. The risk factors described above should also be avoided as much as possible.
Physical exercise: Studies show that physical exercise is good for the bones throughout life. Being active during childhood and adolescence is especially important because it builds a stronger skeleton, which in turn builds up reserves of bone mass for use in adulthood. Physically healthy people develop better balance and coordination, which reduces the risk of falling.
It is recommended to do at least 30 minutes of physical activity at least three times a week. The most important thing is not the duration of the sessions, but their frequency.
Here are the different types of exercises that are recommended.
- Load-bearing joint exercises have a gravitational effect on the skeleton. They force the body to bear the weight of the whole body. These include running, jumping, tennis, and team sports such as soccer.
- Although strenuous activities (cycling, kayaking, and swimming) are excellent for cardiovascular health and maintaining muscle mass, they have no real effect on bone mass.
- Resistance exercises consist of moving objects or your own body in such a way that resistance is generated. They are performed with weights or with the weight machines commonly used in gyms.
- However, the same results can be achieved by performing certain daily tasks that require the handling or pushing of heavy loads. For example, gardening for at least one hour per week would be the second-best exercise after weights.
- Balance improvement exercises, such as tai chi or training that restores correct walking posture should be considered to avoid the risk of falling, if necessary.
Eat foods that are rich in calcium. Almost every cell in the body needs calcium to function properly. A diet rich in calcium will help meet the body’s needs without relying on its reserves, i.e. the bones. Sufficient calcium intake can be achieved by regular consumption of dairy products, salmon (with bones), sardines, dark green vegetables (broccoli, etc.), soy products (tofu, calcium-enriched soy milk).
Take sufficient vitamin D. This vitamin is essential for healthy bones and teeth. It improves the absorption of calcium in the intestines and helps to fixate this mineral in the bones. Its active form is synthesized in the skin when it is exposed to the ultraviolet rays of the sun. Vitamin D in its active form is found in few foods. This is why in North America, milk and margarine are both fortified with vitamin D. Certain cereals, rice, and soy drinks are also fortified with vitamin D.
Other preventive measures
Calcium and vitamin D supplements
- For healthy people under 50: 400 IU to 1,000 IU (10 to 25 µg) of vitamin D and 1200 mg of calcium per day to be supplemented as necessary.
- For persons aged 50 years and over: 800 IU to 2000 IU (20-50 µg) of vitamin D and 1200 mg of calcium per day to be supplemented as necessary.
Medical treatments for osteoporosis
The basic treatment combines the intake of supplements and medication with an adapted exercise program. However, bone loss may recur if the treatment is discontinued.
If osteoporosis is the result of prolonged medication (steroid therapy etc.), the cause must be eliminated quickly.
There are several drugs that can slow bone resorption and significantly reduce the risk of bone fractures. In addition, it is often possible to recover some of the lost bone mass (note that the risk of fracture can also be reduced in situations where bone mass remains stable). Medication is only used if the risk of fracture is considered high.
Here are the most important ones:
Bisphosphonates: These medications slow down the loss of bone mass. The most commonly used are alendronate (Phosamax®) and risedronate (Actonel®) in weekly or daily doses in the form of tablets. A new formulation of Actonel® makes it possible to take this medicine once a month. Etidronate (Didrocal®) is also used in daily doses and intravenously injected zoledronic acid once a year. Ibandronate Brand name: (Boniva™) is another popular drug for the treatment of osteoporosis.
Adverse reactions: Prolonged use of bisphosphates for more than 5 years increases the risk of atypical femoral fractures. Atypical fractures are located at a different site on the bone than those caused by osteoporosis. The risk of osteonecrosis of the jaw also increases, especially in women with weakened immune systems. These side effects are rare but serious. According to a study published in 2011, 0.4% of women are affected by atypical fractures after 5 years of treatment with Bisphosphonates.
Experts say that these drugs should only be used in women at high risk of osteoporosis-related fractures (based on an overall medical evaluation and not just a bone density test). In such women, the benefits of bisphosphates clearly outweigh the risk of adverse effects. Some recommend a break of 1 or 2 years after 5 years of treatment and then starting again.
Calcitonin (Miacalcin®): This hormone produced by the thyroid gland slows bone resorption. It also has an analgesic effect. It can be used nasally or by injection.
Raloxifene (Evista®): This medicine mimics the effects of estrogen by acting on estrogen receptors (without increasing the risk of developing hormone-dependent cancer).
Tamoxifen: This synthetic hormone used in the treatment of breast cancer also has a similar effect to estrogen on bones.
Synthetic parathyroid hormone (PTH): This hormone is secreted by the parathyroid glands and is reserved for cases of severe osteoporosis. It is administered in the form of an injection. It plays a role in the exchange of calcium and phosphorus in the body and delays bone resorption.
NB: Analgesics should be used for acute or chronic pain. A corset may be necessary if the pain increases.
Hormone replacement therapy (HRT) during menopause can help to slow the loss of bone mass and reduce the risk of fractures. However, due to the risks involved, it is rarely used only for this purpose. It should be noted that when hormone therapy is stopped, an accelerated phase of bone loss begins, as is naturally observed in premenopausal women. Men whose osteoporosis is due to a testosterone deficiency (hypogonadism) can be treated with androgenic hormones. This type of hormone therapy also carries risks, such as an increased risk of prostate cancer.
In the case of a hip fracture, surgery is often necessary to reconstruct the hip.
In cases of hyperparathyroidism, removal of the parathyroid glands improves the mineral density of the bones.
Calcium and vitamin D supplements
The doctor sometimes recommends taking calcium and vitamin D supplements. The calcium intake of food and supplements, as needed, should be 1200 mg per day. The recommended dose of vitamin D is between 800 IU and 2,000 IU (20 to 50 µg) per day, depending on the situation.
Measurement of vitamin D (25-hydroxycholecalciferol) in the blood is generally recommended in people undergoing pharmacological treatment for osteoporosis. This allows the doctor to know the ideal dosage of vitamin D that is needed.
Foods for Prevention
As described in prevention, it is a good idea to increase the intake of foods rich in calcium and vitamins. It is also important to ensure a sufficient protein intake and to promote an alkaline diet (rich in fruit and vegetables).
The benefits of physical exercise are many and varied:
- Maintain mobility and balance
- Prevent falls
- Delay the loss of bone mass
- Reduce pain caused by fractures
If you suffer from osteoporosis, you should consult a doctor or physiotherapist before any kind of physical activity. The exercise program should be progressive and appropriate to the individual’s abilities.
Prevention of falls
Several factors increase the risk of falls among older people, such as:
- Loss of muscle strength
- problems with balance
- vision problems
- The use of certain medications (e.g. sleeping pills, anxiety medicines, some antidepressants, and some allergy medicines)
Maintaining good muscle mass and improving flexibility and balance are the best ways to prevent falls. Visiting an occupational therapist can help you to design your living space in such a way that this risk is reduced.
Advice to follow every day
Have a good posture: Straighten your head and keep your upper back straight, keep your shoulders back and your lower back arched.
Neck support: Support your neck with a small pillow when sitting on a chair or driving a car.
Handle heavy loads correctly: Avoid bending your upper body to grasp and lift a load; instead, bend your knees and keep your back straight when going up.
Prevent falls: Use a non-slip mat in the tub; wear shoes with flat heels and non-slip soles; watch out for carpets, slippery surfaces and loose electrical cables, etc.
Domestic animals: Beware of dogs and cats, as their sometimes unpredictable behavior can lead to falls.
Complementary approaches to treating osteoporosis
Tai Chi: In 2008, a systematic review of 7 randomized clinical trials involving 1,972 people was published. The authors concluded that tai chi can reduce falls or the risk of falls in people over 60. However, to be effective, tai chi must be practiced regularly. The preventive effect is less pronounced in very old or fragile people.
Ipriflavone: Data from several clinical studies show that Ipriflavone, taken together with a 1,000 mg calcium supplement, can prevent osteoporosis in postmenopausal women. It also appears that it can slow down or reverse bone loss in people with osteoporosis, including those suffering from certain diseases.
Take 600 mg per day, in 2 or 3 doses, in combination with a calcium supplement of 1,000 mg.
Although Ipriflavone is available over the counter in North America, their use requires follow-up treatment by health professionals in some people due to their potential immunosuppressive effects.
Vitamin K: Epidemiological studies have found an association between low dietary vitamin K intake and reduced bone density and increased risk of fracture. Most of these studies were conducted in Japan. The results are promising but have not yet been confirmed by studies with Western women.
There are not enough data to propose a therapeutic dosage. In some studies in Western subjects, 200 µg to 1000 ug (1 mg) of vitamin K1 per day were used. In studies in Japan, 45 mg of vitamin K2 per day (a very high dose) was often used.
Boron: Results from 3 preliminary studies in postmenopausal women (30 subjects in total) suggest that boron supplements can improve calcium absorption and thus reduce bone density loss.
Collagen: Collagen supplementation can increase and prolong the beneficial effect of calcitonin, a hormone normally prescribed for osteoporosis, on bone mass.
DHEA: Dehydroepiandrosterone (DHEA) is a steroid anabolic hormone synthesized from cholesterol by the human adrenal glands. With increasing age, the body produces less and less. The few studies conducted so far suggest that DHEA supplementation can help maintain bone mass.
Flaxseed: There has been some interest in the usefulness of flaxseed for menopausal bone loss, but the results are generally inconclusive.
Magnesium: Studies have shown a relationship between magnesium intake (diet and supplements) and bone density. Research suggests that magnesium deficiency contributes to osteoporosis. However, clinical studies on the effects of dietary supplements are rare.
Isoflavones: The role of isoflavones in preventing osteoporosis remains highly controversial. Although epidemiological data show a correlation between dietary intake of isoflavones and bone density, the positive effect is thought to be greatest during perimenopause and shortly after menopause. The variability of research protocols, the number of subjects, and the duration of the studies make interpretation of results difficult.
Red clover (Trifolium pratense): Red clover isoflavones appear to have the potential to reduce bone mineral density loss in perimenopausal and postmenopausal women.
Field horsetail (Equisetum arvense): Traditionally, the above-ground parts of this plant have been used to prevent bone loss or to help heal strains or fractures.