Osteoporosis

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Osteoporosis
By Dr. L. William Lauro

(If you have questions you would like Dr. Lauro to answer, send them to [email protected])

Do you know what the biggest killers are in the industrialized nations? Heart attack is first, stroke second, and cancer third. But what about osteoporosis? Is it anywhere near the top three killers? Nah, that is just a disease where your bones weaken, isn’t it? People don’t die from that, do they? You would be surprised.

Did you know that if you live to be in your late seventies, your chance of dying from osteoporosis begins to approach that of cardiovascular disease and cancer. Surprised?

Here is how it works-let’s say you are 78 years old, you have skated past having a heart attack, you have been passed up by cancer (or you have beat the disease if you got it), and then one day you slip on your sidewalk and fracture your hip. You have hip surgery, everything seems to go well, and then a complication develops. At this point 1 in 4 people will never leave the hospital alive.

Yes, if you are an older person, a hip or other serious bone fracture can lead to your death.

Well, why then are the elderly so susceptible to fracture? In one word: osteoporosis.

What is Osteoporosis?

Osteoporosis, in the simplest terms, is a disease where, over time, the bones become decalcified, resulting in thin, weak, and brittle bones, which are very susceptible to fracture. The decalcified bones in this disease have lost their strength and their hardness (i.e. the bone density is reduced).

How Does Osteoporosis Develop?

To answer this question we have to understand what happens in the normal person. Bones are first formed in the fetus by special cells that produce long strands of protein. This new proteinaceous substance is then calcified by other cells called osteoblasts. These results in the hard mass we call bone.

There are also cells that break down bone (osteoclasts). These osteoclast cells constantly remodel the bones. Normal healthy bones exist in a continuum of bone production and bone reabsorption. Normal bone is constantly being formed, remodeled, dissolved, and reformed again. This bone turnover is quite normal and quite useful.

As we approach middle age, however, the bone forming cells (osteoblasts) don’t work as well as they used to. But unfortunately, the bone dissolving cells (osteoclasts) are still very active. This leads to an imbalance in bone formations and reabsorption. Our bones become thinner and thinner as the osteoblasts fall behind the activity of the osteoclasts.

What causes the osteoblast function to deteriorate? There are several reasons. First of all, hormones seem to be a big factor, especially in women. We know that as a woman approaches menopause and her estrogen levels begin to drop, her osteoblast activity declines. At this point one can already see the thinning of the bones under electron microscopy (this is called osteopenia, which is the earliest type of osteoporosis). By the time menopause comes and goes many women have passed into true osteoporosis. But because there are no symptoms of this disease (until you actually break a bone, that is) you don’t even think about it.

Men also develop osteoporosis at this age but at a much slower rate because their hormones levels do not abruptly drop off as in menopausal women. But be forewarned: men do get osteoporosis and do fracture their bones later in life.

Another cause of osteoporosis is inactivity. It is like Lehi said to his son Jacob: there needs be opposition in all things. This could not be more true that in bone health. Bones like stress, they like opposition. When bones are stressed, used, exercised, worked-out, they activate the osteoblasts to produce more bone. This is true even in older people whose hormone levels are dropping. Activity and exercise can build bone! But of course we must be careful not to over do it and actually fracture the bone. We must be careful, especially as we get older.

Low calcium intake also leads to weak bones (although this is less of a factor than low hormones). As we get older we just don’t seem to like milk and dairy products as much (they can be constipating, they taste funny to us, they make us gain weight, etc). As our dairy intake drops, so does our calcium levels. Also, as we age our kidneys are not as perfect at retaining calcium, and some is therefore lost in the urine. Also, we don’t manufacture Vitamin D as well as we age. This vitamin is necessary for the intestines to absorb calcium from the diet. So as you can see, as we get older we need more calcium and Vitamin D in our diets, or taken as a supplement.

Cortisone use (corticosteroids such as Prednisone) can cause osteoporosis. Cortisone accelerates the osteoclast activity, which dissolves bone. Many people are on cortisone for arthritis, asthma, allergies, and for autoimmune diseases. These patients are at high risk for osteoporosis.

Diagnosing Osteoporosis

We would like to detect osteoporosis long before a patient suffers a fracture. This is done through screening with a special test called a bone mineral density test (BMD). These are done quite routinely now and are very accurate. Talk to you doctor about ordering a BMD test if you are a women in your late forties or a man in his fifties, or even earlier if you have a family history of osteoporosis, if you take cortisone regularly, or if you are a woman of thin build and have a ight complection (these women have lower levels of estrogen).

Prevention and Treatment of Osteoporosis

As I mentioned above, the risk factors for osteoporosis are low hormones, physical inactivity, low calcium and vitamin D levels, and cortisone use. In addition, being thin and being light completed are risk factors. I am not suggesting going out and gaining a lot of weight to treat osteoporosis (darn-wouldn’t that be fun?) but I mention this so you know who is at extra risk.

We used to put menopausal women on hormone replacement (animal and synthetic estrogens) just to prevent osteoporosis. This is not recommended anymore, as the use of estrogen can increase the risk of heart attack, blood clots, and breast cancer (see my previous article on hormone replacement therapy). Natural plant estrogens have not been studied enough to determine if they are effective in preventing osteoporosis, but because these plant estrogens might help (and there appears to be no harm in taking them), you can try this. By the way, Progesterone hormone, whether natural or synthetic, does not increase bone formation. This is contrary to what a lot of people believe (as witnessed by the numerous letters I got on my previous hormone article). If you are taking plant progesterone to prevent osteoporosis you are fooling yourself!

So, in the absence of hormone replacement as a viable way to build bone, what can we do? First of all, increasing one’s calcium intake to 1500 mg per day (in three divided doses of 500 mg each) can help slow bone loss. But remember, you must also take Vitamin D with your calcium or you will not absorb the calcium into your body (400 units of vitamin D if less than age 65, and 800 units if older). And don’t fear kidney stones by taking extra calcium-this just does not happen.

Staying active is very important. Exercise stresses the bones and this can cause new bone growth. I am not suggesting you become a body builder, just get out and walk a mile each day and carry some light weights with you as you walk (2.5 lbs in each hand). Exercise also had another benefit: it improves your balance so that you are less likely to fall and fracture a bone in the first place.

Finally, let’s talk about medications. Medical science has developed a new class of drugs that can actually build bone to replace the lost bone seen in osteopenia and osteoporosis. These drugs are not related to the hormone drugs at all. They can be taken just once a week and can rebuild bone by almost 30%, which is quite good. The only drawback is that they can cause irritation to the esophagus, so talk to your doctor about the side effects. The prototype drug of this class is Fosamax. The newest drug on the scene is Actonel.

There is another class of drug, which also can build bone, but I have never been a big fan of it. It is called Miacalcin and is available as a nasal spray. It is expensive and has to be used four times a day. It was popular until Fosamax came on the scene.

One last medication to consider is the class of drugs known as selective estrogen receptor modulators (SERMS). These drugs have estrogen effects without the risk of estrogen (other than blood clots which these drugs can still cause). They also build bone just like estrogen. I have used them a lot in people who cannot tolerate Fosamax. The prototype of this class of drug is Evista.