Contents
Exec. Sum.
Overview
Detection
Risk Factors
Prevention and Treatment
WV Prevalence
NOF Prevalence
Fractures Model
Hospitalizations
WV and US
Costs
Appendix A
Appendix B
Appendix C
Appendix D
References |
Osteoporosis Prevention and Treatment
Primary | Secondary
| Tertiary
The development and progression of osteoporosis is dependent on two
separate processes: the formation of bone mass during childhood and young
adulthood and the rate of bone loss in later life. The activity of the
cells involved in the formation and regeneration of bone tissue is regulated
by many factors, including hormonal levels and balances, diet, the metabolic
effects of caffeine intake and cigarette and alcohol use, and external
physical forces such as body weight and exercise. Because of the complex
nature of osteoporosis, its prevention and treatment must be comprehensive,
emphasizing diet, exercise, drug and hormonal therapies, and behavioral
changes.
Primary Prevention. The best defense against osteoporosis
is the accrual of maximum bone mass in childhood, adolescence, and young
adulthood. Primary prevention includes educating youth on the dangers
of bone disease in later life, with an emphasis on the importance of diet
and exercise in earlier years.
- Children and adolescents should be encouraged to participate in sports
activities and other physical exercise. Lifetime sporting activities
such as tennis, hiking, and running should be promoted as well as school
sports. Young women need particular encouragement to continue to exercise
regularly to build better bones.
- Parents need to be made aware of the important role of calcium in
their children's diets in building and maintaining bone. The National
Institutes of Health recommends that children aged 1 through 10 years
receive from 800 to 1,200 mg of calcium every day, while adolescents
and young adults aged 11 through 24 years need from 1,200 to 1,500 mg
daily. (6). Families should be counseled on the benefits of drinking
skim or 1% milk to lower their fat intake while still getting their
necessary calcium. Diets low in calcium should include a calcium supplement.
- Optimal calcium absorption requires adequate levels of vitamin D,
which are normally obtained from exposure to sunlight (as little as
10 minutes per day). Unless they are home bound, children and young
adults rarely need a vitamin D supplement.
- The roles played by cigarette smoking and immoderate alcohol use and
caffeine consumption in the development of osteoporosis need to be emphasized
in the health education of young people.
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Secondary Prevention. Secondary prevention activities should
be promoted among middle- aged and older adults who are at risk for osteopenia
and osteoporosis. Hormonal therapy, weight-bearing exercise, and calcium
supplementation are the major forms of prevention among these ages. Bone
mass screening through bone densitometry is often recommended for high-risk
individuals.
- Estrogen replacement therapy has been shown to be by far the most
effective treatment in reducing bone resorption and retarding bone loss
in postmenopausal women. Overall fracture risk is reduced by more than
50% in women who start hormone replacement therapy (HRT) early in their
menopause (either surgical or natural) and continue it for a minimum
of six to nine years. Even administering HRT to women many years past
menopause has been shown to be beneficial in slowing bone loss. The
positive effects of HRT last only as long as the therapy is continued,
however, with increased bone loss occurring when therapy is stopped.
For maximum protection, it is recommended that HRT be continued for
at least 10 years following menopause. There are certain contraindications
to HRT, including breast cancer or a strong family history of breast
cancer, active liver disease, unexplained vaginal bleeding, and active
vascular thrombosis; however, studies are currently under way on a low-dose,
plant-based estrogen that appears to have fewer risks and side effects.
Each woman needs to weigh the risks and benefits of HRT individually
with her physician.
- At any age, physical activity positively affects bone mass. Exercise
programs in middle life need to be aimed at increasing strength, coordination,
balance, and flexibility. A regular regimen of weight-bearing exercises
in which bones and muscles work against gravity is recommended. Such
exercises include walking, tennis, stair climbing, and weightlifting.
- The NIH recommends an intake of 1,000 mg of calcium among adult women
aged 25-49 who are premenopausal and those aged 50-64 who are postmenopausal
but taking estrogen therapy (6). Women aged 50-64 who are not taking
estrogen and all women aged 65 and older need 1,500 mg. The recommended
intake is 1,000 mg for adult men aged 25-64 and 1,500 mg for men aged
65 and older.
- Most physicians now recommend bone density measurement for individuals
at high risk for osteoporosis. These include postmenopausal women who
are not on hormone replacement therapy; women with a family history
of osteoporosis who have early onset menopause, amenorrhea, or a low
body weight; persons with x-ray evidence of osteopenia; persons on long-term
glucocorticoid therapy, or individuals with hyperthyroidism or hyperparathyroidism.
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Tertiary Prevention. Tertiary prevention activities involve
middle-aged and elderly individuals who have been diagnosed with osteoporosis or have
already suffered an osteoporotic fracture. These activities are aimed at limiting future
disability and aiding rehabilitation. Exercise programs, better nutrition, and drug
therapy are all components of a comprehensive regimen designed to treat established
osteoporosis.
- Fall prevention education and management is vitally important among the elderly. Nearly
nine out of every ten fractures (87%) among older persons (aged 65+) are caused by falls.
According to the National Center for Injury Prevention and Control, falls are the second
leading cause of injury death among persons aged 65-84 and the leading cause among persons
aged 85+ (7). Fall prevention programs targeted at persons with osteoporosis stress
exercises that improve balance and coordination. As inactivity increases the risk of
falling, even physically deconditioned persons with osteoporosis need a moderate exercise
program tailored to their individual abilities and limitations. The Journal of the
American Medical Association reported in 1994 that a one-year trial of high-intensity
strength training by postmenopausal women had a positive effect on their bone density,
muscle mass, muscle strength, dynamic balance, and overall physical activity level (8).
Even frail nursing home residents were found to be capable of performing the recommended
twice-weekly strength-training exercises and experienced improvements in mobility, thus
reducing their risk of a fall. Improved physical fitness in an elderly patient also can
result in less pain in the performance of daily activities.
- Calcium absorption is often a greater problem among the elderly, especially those who
are home bound or in nursing homes. These individuals are at risk of vitamin D deficiency
because they are not exposed to sunlight on a frequent basis and may need a vitamin D
supplement to meet their daily requirement.
- In addition to HRT, several other drug therapies are currently available that limit the
progression of established osteoporosis. Biphosphonates are a new class of drugs that
increase bone mass by inhibiting bone resorption. They offer an alternative to HRT in
postmenopausal women and may be useful in men and patients undergoing long-term
glucocorticoid therapy. Two biphosphonates, etidronate and alendronate, are presently
being used to treat established osteoporosis, and others are undergoing clinical trials.
(While not yet FDA approved for the treatment of osteoporosis, etidronate has been
approved for other bone diseases and is prescribed extensively for osteoporosis as well.)
Approximately 80% to 85% of patients have been shown to maintain or increase bone mass
with biphosphonate therapy (5).
Calcitonin is another drug therapy that has been approved by the FDA for the treatment
of osteoporosis. Calcitonin is a natural hormone that increases bone density by slowing
the rate of bone loss and also relieves bone pain in some patients. It is administered
either as an every-other-day injection or as a once-a-day nasal spray.
A new class of drugs called selective estrogen receptor modulators, or SERMs, are being
clinically tested as an alternative to HRT. These drugs act as estrogen in the skeleton
and cardiovascular system, while blocking estrogen's effects in the breast and uterus. If
FDA approved, a SERM called raloxifene could be available in 1998.
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