SILENT EPIDEMIC ROBBING HEALTH

An ongoing silent epidemic is beginning to grab more attention among professional healthcare providers and among the general population. This disease is said to affect primarily post-menopausal women but has been seen in women as young as their twenties and also in men. The World Health Organization considers it a major threat with more than a million and a half cases, more than heart attacks and strokes in women. Its direct costs are $14 Billion and it is responsible for 180,000 nursing home admissions.
The epidemic is osteoporosis.

Osteoporosis is a skeletal bone disease characterized by decreased bone density, increased brittleness and fractures. Fractures often result from no apparent trauma. The spine, hip and wrists are most frequently broken. Osteoporosis primarily affects post-menopausal White or Asian women, particularly those of light frame and build. However, Hispanics, Blacks and men also suffer from this condition. Arthritic patients, people with asthma, seizures and those with an overactive thyroid are at increased risk because certain medications, particularly corticosteroids, can promote the loss of bone mineral. Loop diuretics such as furosemide used to treat high blood pressure, edema and heart failure may also contribute to the development of osteoporosis. If you are taking a corticosteroid, anticonvulsants, thyroid hormones or furosemide, you need to continue to take your prescribed medication. Suddenly quitting any of these drugs may be more dangerous to your health. However, you may want to discuss your concerns with your doctor and read further to learn how to identify your risks and possibly prevent more rapid bone thinning.

Independently acting risk factors have been identified. Normal menopause is on average at age 52 years. Surgical menopause (removal of the ovaries) or an early natural menopause before age 45 is associated with higher risk for developing osteoporosis. Having a mother, grandmother, sister or any family history of a relative with the disease puts one at higher risk, too. Certain drugs, gender, race and build have already been mentioned. Other potential risks, which are more controversial, include dietary habits and lack of exercise. Girls beginning in their early teens should be eating a diet rich in not only calcium, but also magnesium and other minerals. A diet higher in calcium may also help ward off premenstrual symptoms so that health benefits just may be more immediate. Diets of fresh fruits and raw vegetables, especially dark green leafy ones, have added plant nutrients that are most desirable. Furthermore, avoiding soft drinks may help maintain the calcium one needs and prevent or slow the minerals leaching from bones.

Scientists estimate that nearly 4 out of 5 cases are undiagnosed and therefore untreated. An additional 1 out of 7 is diagnosed but remains untreated which leaves only 1 of every 11 cases properly treated. Osteoporosis is responsible for 400,000 hospital admissions with the associated tremendous cost to human lives and healthcare economics. Fully one-half of hip fracture patients never fully recover and 1 in 5 sufferers of a hip fracture die soon after the injury from secondary complications like lung clots, pneumonia or heart failure. For a middle-aged woman of 50 years, four of every 10 will suffer some type of fracture before they die. More than fifteen percent will break their spine in a compression fracture, which might lead to a deformation commonly known as Dowager’s hump. Seventeen percent will break their femur (thigh bone) or hip and close to another 17% will break a wrist or more accurately, a forearm in what is termed a Colle’s fracture. These concerning statistics are the cause of an awakening attention. Although not considered a deadly disease like hardening of the arteries or cancer, osteoporotic fractures clearly have significant risk of death and morbidity. Often, a fracture is the first indication that a person has this disease just as a heart attack is often the first sign of cardiovascular disease.

People suffering from the consequences of osteoporosis often suffer severe pain, particularly with compression of the backbone. With compression comes loss of height, sometimes up to 3 or 4 inches. The disfigurement, termed kyphosis, leads to loss of self-esteem and depression. Breathing becomes more labored with diminished lung capacity and the risk for pneumonia climbs. Bloating and acid reflux are common as the abdominal cavity is compressed and the abdominal organs protrude forward by necessity giving the added appearance of obesity. Finally, this poor broken person has a propensity to falling. A patient with a vertebral fracture has double the risk for breaking a hip in the near future. Do not forget that the elderly often already have dizziness that makes it easier to fall in the first place.

The gold standard diagnostic test is a DEXA scan. DEXA is an acronym for Dual Emission X-ray Absorptometry. There are recent advances as to how to best use DEXA results. One is given a T-score, which is a statistical measure of one’s bone density compared to a normal young adult. Traditionally, a standard cut-off point below which you have osteoporosis is used. However, new research has accumulated whereby we now can define real world fracture risk associated bone mineral density results from many manufacturers’ models. DEXA tests can give erroneously high density results for the backbones in patients with mineralized hardening of the arteries, severe degenerative arthritis, or sometimes even constipation. Quantitative CT or computed tomography is another method to diagnose osteoporosis. There are still some diagnostic dilemmas with this method, too. Ultrasound is now being used as a screening for bone mineral density. All these methods can only diagnose the condition after the bone mineral density has decreased to a point where the risk for fractures is high. To determine the rate of lost bone density, one needs to repeat the tests after a period of time and calculate the rate.

A noninvasive test can reveal the rate of bone metabolism that may prove to be very useful in the area of prevention and in monitoring therapy for osteoporosis. It does not distinguish among the various causes of bone mineral loss, such as Paget’s disease or cancer that has spread to bones. This test is a dynamic test that measures the urine content of two markers of bone turnover. These are pyridinium and deoxypyridinium. The test is affordable and requires no needles.

What do you do if you are diagnosed with osteoporosis? It is prudent at this point to consider pharmaceutical therapy in addition to nondrug supporting measures. The primary drugs to combat osteoporosis are estrogen hormone replacement, bisphosphonates, calcitonin (a hormone from the thyroid gland derived from salmon) and a selective estrogen receptor modulator. Estrogen is the standard hormone for post-menopausal replacement therapy. It improves or eliminates symptoms of menopause and is proven to increase bone mineral density. The actual benefit in terms of reduced fractures is uncertain. Estrogen replacement has heart benefits as well. However, in women who have not had their uterus removed, estrogen therapy without progesterone runs a higher risk for the development of endometrial cancer. Ralioxiophene is a selective estrogen receptor modulator (SERM) that also increases bone density a few percentage points and reduces spinal fracture risk. The trade name of this drug is Evista that is somewhat costly, but in patients in whom a devastating fracture is prevented, is worth the expense. It does not seem to increase the cancer risk. Bisphosphonates include two drugs: Fosamax and Actonel. These drugs decrease bone resorption and are proven to reduce fracture risk for spinal and hip fractures. Fosamax is cumbersome to take as it must be taken on an empty stomach with water only at least 30 minutes before a meal. It has a propensity to induce reflux and heartburn, which are not uncommon in the patient before the drug was prescribed. Actonel had similar stomach problems to placebo. Both are expensive. Calcitonin comes as a nasal spray. It increases bone density 1% but reduces spinal fractures 36%.

Nonprescription support is also useful. Weight-bearing exercise has shown to improve bone mineral density 1%. The increased strength and balance resulting from exercise help reduce the overall risk of falling. Unfortunately, many elderly patients cannot adequately exercise. For these, tai chi, yoga or water therapy may prove beneficial.

Dietary calcium is needed. About 1500mg daily should be consumed primarily in your food but also by supplements if needed. Mineral supplements are usually necessary. In the mineral family, magnesium, manganese, boron, and fluoride may all be useful and important to strengthening bones.

Vitamin D is required for proper calcium absorption and metabolism. Sunlight converts precursors in your skin to the active form. However, one study demonstrated that over half of hospitalized patients were deficient in this vitamin. Vitamin K is also important for bones. Many people are deficient of Vitamin K because overuse of antibiotics or malabsorption problems lead to a decrease of friendly gut germs that manufacture Vitamin K. Vitamin K is fat-soluble and thus can become toxic if given in the wrong form or if too much is taken.

Other patented nutraceuticals have also been reported to support bone healing and increase bone density.

When should prevention of osteoporosis begin? As a person grows, bone mineral is increasing up to about age 30. After the early 30’s, bone mineral is lost more rapidly than it is gained. At menopause, with the precipitous drop of estrogen, bone loss is rapid. A woman may lose about 50% of her cortical bone thickness during her life. Certain drugs also promote the loss of bone mineral. The standard recommendation is that at menopause, a DEXA baseline should be obtained and estrogen therapy begun. If there is a family history, monitoring should begin sooner. If one has osteoporosis already at this time, then additional pharmaceutical therapy is warranted. If a woman does not have osteoporosis but does have decreased bone density, close follow-up is needed to monitor the progression of the condition. Certainly, dietary calcium, Vitamin D and exercise are suggested supporting measures. A person who needs to be on one of the drugs such as anticonvulsants or corticosteroids should be closely monitored for developing a drug- induced osteoporosis. People on thyroid replacement should have regular monitoring of their thyroid function. With the noninvasive urinary test of bone metabolism, a healthcare provider should be able to screen for evidence of high bone metabolism before other testing reveals a severe loss of bone mineral. In patients where these markers are elevated, DEXA scans and the full preventative supporting measures is suggested. Perhaps the bone metabolic screening should be considered by women in the pre-menopausal years, especially if other risk factors are present. Importantly, primary prevention should begin in teenagers with improved food choices and avoidance of high phosphate foods like sodas and moderation of red meats.

Bryan Turner, DVM, MD holds doctoral degrees in veterinary and human medicine. He has a private general practice that focuses on preventative and nutritional health.
The Jordan Health and Wellness Center is located at
10393 South 1300 West Suite 102 in South Jordan, UT.
The office phone number is 801-302-5827.