Osteoporosis

Cecilia, Joelle, Stephanie, Rachel

Osteoporosis: A disease of the bones

Definition: a medical condition in which the bones become brittle and fragile
from loss of tissue, typically as a result of hormonal changes or deficiency of
calcium or vitamin D.
Occurs when

Bones break down too quickly

Bones arent able to build back up quick enough

Incidence and Prevalence

Incidence and Prevalence

10 million with osteoporosis (8 million women, 2 million men)

2 Million broken bones every year

43 million with osteopenia

50% of women
25% of men

19 Billion in costs (80% of costs are paid by medicare)

37,500 people die each year from complications related to osteoporotic fractures

A womans risk of breaking a hip due to osteoporosis is equal

to her risk of breast, ovarian and uterine cancer combined.
And a man age 50 or older is more likely to break a bone due
to osteoporosis than he is to get prostate cancer

A Growing Problem

25% of the US population will be over 65 yrs old by 2020

Bone Anatomy

What is a Bone?

A Bone is both an organ AND a tissue

Functions:

Protection
Shape/Structure
Movement
Synthesis of blood cells (bone marrow)
Mineral storage

What are the differences between cortical bone and

trabecular bone?

Two major types of bone tissue

Cortical/compact: 80%
Shafts of long bones, around trabecular bone, vertebrae
Very dense (5-10% porosity)
Trabecular/cancellous: 20%
Ends of bones, iliac crest of pelvis, wrist, scapula, vertebrae
Less dense (Sponge bone- 50-90% porosity)
Adds support to cortical bone shell

Bone Physiology

Bone Cells

Osteoclasts: govern the resorption or breakdown of bone

Osteoblasts: responsible for the formation of bone tissue

Degradation via enzymes and acid secretion

Synthesis of matrix proteins
Mineralization

Osteocytes:

Formed when an osteoblast becomes embedded in the matrix it has secreted

Describe bone modeling, when does it occur?

Bone modeling: The growth of the skeleton until mature height is achieved (long
bones elongate and widen)

Females by ages 16-18

Males by ages 18-20

What factors affect Peak Bone Mass?

Peak Bone Mass (PBM): Age 30

Consolidation: filling in of osteons in the shafts of long bones

Genetics (70-80% of bone health)
>Men
Diet
Exercise
Eating disorders and chronic diseases

Describe bone remodeling.

Bone Remodeling: process in which bone is continuously resorbed through the

action of the osteoclasts and reformed by osteoblasts

Trabecular bone
Happens quickly in normal young adults

How is bone remodeling regulated?

Activation of preosteoclastic cells in bone marrow

Migration of cells to surfaces of bone while differentiating into osteoclasts
Resorb both bone mineral and matrix on the surface of bone

release acids and proteolytic enzymes

Forms small cavities on bone surfaces
resorbing is rapid (few days)

Rebuild by refilling cavities by osteoblasts

secretion of collagen and other matrix proteins

Salts of calcium and phosphate precipitate on collagen fibers to develop into crystals of
hydroxyapatite
slow (3-6 months or years, for older adults)

Why does the bone remodel itself?

Benefits:

Renewal of bone without any microfractures

Helps adapt to changes in lifestyle and dietary intakes
Calcium Homeostasis

Calcium Homeostasis

Process of maintenance of a constant serum calcium concentration (10 mg/dL)

Bone tissue = reservoir of calcium and other minerals

Regulated by

99% of calcium is found in the bone

1% is critical for life processes
Parathyroid hormone
Active Vitamin D

Three sources of Calcium

Bone
Gut
Kidney

Calcium
in Blood

Bone

PTH

Kidney

Vit D

Calcium
in Blood

Stomach

Pathophysiology

Causes of bone loss

Age
Low dietary calcium
Low estrogen (Menopause)
Underlying disease
Medication

Causes of Bone Loss: Low Dietary Calcium

Persistently elevated PTH concentration

Large amounts of bone tissue removed and not replaced

Causes of Bone Loss: Age

Age 40: Bone begins to slowly diminish (Males and Females)

Age 50 (or after menopause): Bone loss increases greatly for a decade (Females)
Age 70: Both Males and Females reach about the same loss rates

Causes of Bone Loss: Underlying diseases

Rheumatoid arthritis
Celiac disease
Diabetes
Multiple Myeloma
And many more.

Risk Factors/Prevention

What factors increase risk of osteoporosis?

alcohol and cigarettes: toxic effect on osteoblasts

moderate alcohol intake: possible positive effect in postmenopausal women

excessive alcohol intake: may result in bone loss
combination of smoking and alcohol = increased risk

low body weight

heavier weight = stronger skeleton

lean body mass has greater effect than fat mass
however...adipose tissue increases inflammation, which increases osteoclast activity

What factors increase risk of osteoporosis?

Ethnicity

Lactation

bone loss in women who breastfeed for 6 months or longer

need to consume adequate vitamin D and calcium

Lack of menses

Whites and Asians have more osteoporotic fractures

Blacks and Hispanics have greater bone density

menopause: lack of estrogen, increased osteoclast activity/numbers

amenorrhea also associated with bone loss

Medications

interfere with calcium absorption

promote calcium loss from bone

What factors decrease risk of osteoporosis?

weight-bearing exercise

good diet + exercise, esp. at age 10-20

accumulation of bone mass/density

reduces skeletal inflammatory markers

in frail older individuals

muscle contraction...stimulates
osteoblast function

Prevention

Avoid falls

for older at-risk individuals

to avoid injury with lower bone-density

how to reduce risk:

assisted living, monitoring

padded hip girdle
Design of living space
grab bars to get in and out of tub
Bath stool or chair in shower
Good lighting
Skidproof flooring

Prevention: adequate nutrients

adequate calories

Anorexia is a cause of osteoporosis

Not enough body fat = less pressure on bones, sometimes amenorrhea

protein

Low protein intake significantly related to bone loss

Adequate protein intake = reduced hip fractures

Prevention: adequate nutrients

Calcium

food vs. supplements

Better to get calcium

from food
absorption

Vitamin D

people at risk?

Phosphate

Supports bone building

Diagnosis

WHO has defined Osteoporosis based on bone density:

Osteoporosis is bone mass at or under 0.871 g/cm2

Types of Osteoporosis
Primary Osteoporosis:
Postmenopausal, most common.
Secondary Osteoporosis:
Caused by hormonal imbalances, medications, and other substances.

Tools to Diagnose
DXA

Central:

Peripheral:

Using a DXA scan.

Smaller scanner.

Scan on lower spine, and hip.

Scan on wrist, heel, fingers, leg.

Best to predict risk of fracture.

Skeletal Sites Used to Diagnose

Lower spine + Hip

Forearm

If spine and hip cannot be measured or interpreted

Patient is very obese.

DXA Scan Results

T-Score: Compares your bone density with peak bone density.

Z-Score: Compares your bone density with others of your age, gender, and race.

Interpreting Results
T-Score: -2.5 or less at the femoral neck is diagnostic of osteoporosis.
T- or Z- score: neg numbers = thinner than expected; pos numbers = denser than expected
For patients <50 years old:

z-scores are preferred, especially with children.

z-score > -2.0 = within expected range for age
z-score < -2.0 = below the expected range for age

FRAX (Fracture risk assessment tool)

Looks at risk over the next 10 years.
1. Enter relevant information.
2. Results indicating need for treatment.
a.

risk of major osteoporosis related fracture >20%

b.

risk of hip fracture >3%

https://www.shef.ac.uk/FRAX/tool.jsp

Medical Treatment

No Cure
Goals:

Manage symptoms
Slow or prevent disease progression
Potentially rebuild some lost bone density

Medications
Two types

Antiresorptive Medications

Inhibit bone breakdown

Anabolic Drugs

Increase bone formation

6 Classes of Osteoporosis Medication

Bisphosphonates

Antiresorbers on osteoclasts to reduce their bone-degradative activities.

Reduces the incidence of new fractures

Calcitonin

Blocks the stimulatory effects of parathyroid hormone to inhibit osteoclastic bone

resorption.
Improves bone mass density
No often used anymore

Bisphosphonates
Alendronate
Generic Alendronate and Fosamax
Oral (tablet)
Daily/Weekly
Alendronate
Fosamax Plus D (with 2,800 IU or 5,600 IU of Vitamin D3)
Oral (tablet)
Weekly
Ibandronate
Boniva
Oral (tablet)
Monthly
Ibandronate
Boniva
Intravenous (IV) injection
Fo

Medications Continued...
Estrogen

Usually only recommended to individuals also looking to control other

menopausal symptoms
Potential side effects

Estrogen agonists/antagonists AKA selective estrogen receptor modulators (SERMS)

Stimulate estrogen receptors in the bone tissue (not in the uterus or breast)

Hormone Replacement Therapy

Risks

Increased breast and endometrial cancer risk

Increased risk of heart attack, stroke, blood clots, and mental decline

Benefits

Also helps with menopausal symptoms

Increases bone mass and decreases bone loss

Women should assess with their healthcare provider whether the benefits outweigh
the risks.

Medications Continued...
Parathyroid Hormone

Increases osteoblast number and function

Increases bone mass density

RANK ligand inhibitor

Inhibits RANKL, which is a regulator of osteoclast activity

Teriparatide (forteo)
It is a piece of the parathyroid hormone molecule
It is the only anabolic drug

Builds bone (especially in the spine), and helps reduce the risk of bone breakage

Hip Fractures and Surgery

Hip fractures are the most common injury in individuals with osteoporosis.
If you fracture your hip, you will probably need surgery to repair it

The type of surgery done on a patient depends on the type of fracture

Intracapsular Fracture

The head of the femur is broken

The socket (acetabulum) is often also broken

Intracapsular Fracture Surgeries

Compression screw
Individual screws
Total hip replacement

Intertrochanteric Fracture

Intertrochanteric Fracture Surgeries

Compression hip screw
Intermedullary nail

Nail in the hollow cavity of the femur

Subtrochanteric Fracture

Subtrochanteric Fracture Surgeries

Long intermedullary nail

Physical Therapy

The first day after surgery the patient will begin work with a physical therapist
The patient will work with a physical therapist twice a day while in the hospital
and three to four times a week after returning home
Some exercises:

Contracting and relaxing the muscles of the leg and buttocks

Ankle pumps

Physical Activity:

PA is an important part of recovering from hip surgery

The patient should be able to resume normal PA within three to six weeks

Medical Nutrition
Therapy

Diet

Overall healthy diet

Calcium and Vitamin D- essential to bone health
Calcium Supplements are typically recommended to individuals with
osteoporosis, although their safety is still being studied.
Vitamin D is often added to calcium supplements since an individual deficient in
calcium is often also deficient in vitamin D.

Calcium Supplements
Calcium RDA:

Men: 1200 mg
Women: 1000 mg

For healthy individuals, the RDA should ideally be reached through oral intake

UL: 2500 mg for most people

UL: 3000mg in lactation, pregnancy, and youth ages 9-18

Excessive calcium intake can be dangerous

Risks of Excessive Calcium Intake

Bone meal or dolomite supplements could be contaminated with harmful

substances (cadmium, mercury, arsenic, or lead)
Urinary tract or renal stones
Hypercalcemia
Decreased absorption of other minerals like iron
Constipation

NOF Supplement Recommendations for Osteoporosis

Calcium: 1000 mg/day
Vitamin D: 800-1000 units/day
Overall, studies have shown that these levels are both safe and sufficient. These levels
also show a decreased fracture risk and increased bone mass density.

Case Study

Assessment

GS, 73 year old Caucasian retired homemaker

Spine humps over and lower abdomen protrudes forward. Curvatures in upper
thoracic and lower spine regions.
5 5 and 120 lbs in her prime

Has lost a few inches and weight since then

Dietary history: didnt drink a lot of milk. Taught that dairy products were
fattening.
Went through menopause in early 50s. Did not see a need for hormone
replacement therapy.

Sister diagnosed with osteopenia 2 years ago. Placed on a SERM called Evista
(raloxifene)
Two days ago, GS tripped and fell. While on her back, her right foot was 3 inches
shorter than the left and was pointing sideways.
Lab values

Na + 133
Ca++ 9.4 (normal)
BUN 10
Albumin 3.5

Diagnosis

Diagnosed with right hip fracture. Neck of the femur shattered.

Scheduled surgery for total hip replacement.
Severe osteoporosis
DXA scan revealed T-score of -3.5

PES statement

Low dietary intake of calcium and vitamin D related to poor intake of dairy
products as evidenced by low bone mineral density

Intervention

Supplements

Calcium: 1000 mg/day

Vitamin D: 800-1000 units/day

Will be in physical therapy for 4-6 weeks

Recommend improving living environment
when back home to prevent falls

Monitoring and evaluation

1 week follow up after surgery to assess bone mineral density, diet, and physical
activity and recommend further treatment.

Sample diet

Breakfast

1 cup greek yogurt

Banana
cup granola

Lunch

1 cup broccoli cheddar soup

cup cooked carrots
Wheat roll

Snack

cup sliced red peppers

2 T ranch dressing
Nutrigrain bar

Dinner

Snack

1 cup oatmeal
Scrambled eggs
1 cup skim milk

4 oz meatloaf
1 cup mashed potatoes
cup gravy
cup corn

Snack

Apple
2 Tbsp peanut butter
1 cup skim milk

Calories: 2380

Calcium: 1550 mg

Protein: 115 g

Vitamin D: 10 mg