Osteoporosis is a common but serious condition where bones become brittle and fragile due to a loss of density.
According to the ‘Burden of Disease Analysis 2012-2022’[1] report by Osteoporosis Australia, it’s said that in 2012, 4.74 million people in this country aged over 50 years (or 66 per cent of this age group) had either osteoporosis, osteopenia (loss of bone mineral density) or poor bone health.
Within this group, it’s reported that 22 per cent had osteoporosis and 78 per cent osteopenia. Concerningly, the report estimated that by 2022, 6.2 million Australians over the age of 50 would have osteoporosis or osteopenia.
Understanding the definition
Professor Jacqueline Center, senior staff specialist endocrinologist at St Vincent’s Hospital in Sydney and co-lead of the skeletal disease program at the Garvan Institute of Medical Research, says osteoporosis is a “deterioration of bone strength, which increases the risk of fractures”.
“You can think of it as a bone that will fracture under circumstances where you wouldn’t expect it to fracture in a young person,” she said.
She refers to these circumstances as “low trauma” accidents, such as falling while walking or jogging.
“If a young person falls over, you wouldn’t expect them to break a hip,” she said, adding that if an older person had a similar fall and experienced a fracture, then typically it would be due to “weaker bones”.
“If they had essentially the same strong bones as a younger person, they wouldn’t have a fracture,” she added.
However, there’s more to understanding what osteoporosis is than simply bone density, says Professor Center, with osteoporotic fractures an important concept here: someone who has had a “low trauma fracture” is also considered as having osteoporosis, or as being at increased risk of fracture.
“If your bone density is low enough – in other words, it’s 2.5 standard deviations below [that of] a young person – it’s defined as osteoporosis,” she said. “But osteoporosis is also someone who has a low trauma fracture – in other words, a fracture from a simple fall where you wouldn’t expect a bone to fracture. That’s also osteoporosis. That’s an osteoporotic fracture. And yet that person may have a bone density that’s not as low as the 2.5 standard deviations or lower.
“Anyone who has had a low trauma fracture should be thought of as having osteoporosis or should be thought of as being at increased risk of fracture because that’s what we’re trying to prevent.”
Signs and symptoms
The most common symptom of osteoporosis is a decrease in bone density, which makes bones more brittle and prone to fracture, leading to pain and reduced mobility. According to the Mayo Clinic[2], while there are no early signs of bone loss, once someone has osteoporosis, other signs and symptoms may include “back pain caused by a fractured or collapsed vertebra, loss of height, and a bone that breaks much more easily than expected”.
Professor Center pointed to height loss as another factor.
“Two-thirds of spine fractures are asymptomatic,” she said. “So, if you notice someone is arthritic, is bent over, or someone can no longer reach up to the cupboard they used to be able to reach, that should also be a red flag.”
Causes and risk factors
Some of the common osteoporosis risk factors, according to Healthy Bones Australia[3], include:
- Family history.
- Low calcium and vitamin D levels.
- Medical history. (Conditions that can increase the risk of osteoporosis include coeliac disease, diabetes, and anorexia nervosa.)
- Lifestyle factors, such as low levels of physical activity, smoking, and excessive alcohol consumption.
- Body build and weight.
“There are many causes,” Professor Center said. “A large portion of it is genetic. So, if there’s a family history of osteoporosis or fractures, then there’s a greater chance that the person is going to have osteoporosis. As you get older, bone density declines, and in women, it declines fairly rapidly after menopause, at least for the first five years or so, but then it continues to decline.”
She adds that in men, bone density also declines, but not at that rapid post-menopausal rate of decline.
“So, by the time you’re 85-90, a great deal of the population will have low bone density or osteoporosis,” she said.
Body weight is another risk factor for osteoporosis, Professor Center says.
“Very low weight is associated with osteoporosis or low bone density,” she said, adding that hormones, particularly oestrogen levels, also factor in. “Early menopause, for instance, [is a concern] because you start losing the bone earlier.”
Professor Center cites a number of health conditions and medications that increase osteoporosis risk, including steroids (prednisone), hyperparathyroidism, kidney disease, liver disease, and those with diabetes. She adds that data suggests those with diabetes are at an increased risk of bone fractures.
Other risk factors for osteoporosis include low calcium and vitamin D levels, alcohol consumption (particularly if in excess), smoking and falling often, which she says puts someone at risk of fracture, including “anyone who’s already had a low trauma fracture”.
Prevention and management
The best way to prevent osteoporosis is to maintain a healthy lifestyle. This includes a balanced diet, rich in calcium and vitamin D, exercising regularly (particularly weight-bearing exercise), and avoiding smoking and excessive alcohol consumption. Taking calcium and vitamin D supplements can also help reduce your risk.
The key here, according to Professor Center, is that “you want to get the best bone density that you can for your genetics, and then after that, it’s a question of trying to stop the rapid loss” through the various lifestyle factors, including diet and exercise. It’s important, she points out, in younger as well as older people, “to try and achieve your greatest peak bone density”.
When it comes to nutrition, while calcium and vitamin D are important, also key, says Professor Center, is adequate protein intake, which she acknowledges can be an issue, particularly among older Australians.
“One thing we know with older people is that sometimes they don’t have enough protein in their diet … and protein is important in building bone … there have been some studies post fracture looking at supplementing with protein that led to better outcomes,” she said. “Undernutrition, including protein, particularly in older people, isn’t good.”
Addressing prevention and management of osteoporosis, community pharmacist and accredited herbalist Gerald Quigley says it’s “all about minimising the risk”, which he adds “is not all too difficult”.
“As long as you have good nutrition, so plenty of calcium, and you’ve just got good core strength [through] appropriate exercise, which doesn’t have to be pounding the streets … in most instances, it will reduce the risk [of osteoporosis],” he said.
Both he and Professor Centre say food is the best source of calcium and vitamin D.
For calcium intake, Mr Quigley points to sources including regular dairy, fish with soft bones, green leafy vegetables and almonds. He adds that it’s important to enhance the absorption of the calcium being consumed.
“We have to enhance the ability of the body to absorb calcium with vitamin D3,” he said, adding that vitamin K2 is also important “because … that’s been shown to steer calcium into bones and away from blood vessels”.
“There are some magnificent calcium supplements on the market,” he continued, adding that some of the better supplements now contain calcium in a lower dose with vitamin D3 and K2, and are taken two or three times a day.
While Mr Quigley says he prefers capsules to tablets, due to their absorption capabilities, he believes supplements generally are a great option, particularly for those who don’t consume enough minerals, such as calcium, through their diet.
Professor Center says that while a food-first approach is recommended, supplements may be required when dairy consumption is inadequate or if someone can’t tolerate dairy foods due to issues such as lactose intolerance. But she adds that blanket supplementation “isn’t a good idea”.
She says this is also the case for vitamin D.
“Supplements should be considered only if [vitamin D levels are] low on a blood test,” she said, although she adds that vitamin D supplementation may be useful for those who “can’t get outside [to absorb vitamin D from the sun] – for example, those in nursing homes”.
Role of pharmacists
Mr Quigley suggests that to help raise awareness around osteoporosis and encourage prevention/management through lifestyle options, pharmacists and pharmacy staff “could be handing leaflets out with every calcium [supplement] sale, with all sorts of ways of tying that [lifestyle measures] in to help people understand that they can play a very, very important role in reducing their risk of osteoporosis”.
Pharmacies could also consider the in-store provision of a body scan service via DEXA (dual-energy x-ray absorptiometry) which is typically used to measure bone mineral density and a person’s rate of osteoporosis.
“A single scan doesn’t tell you much [because] osteoporosis is a reduction over time of your bone mineral density, Mr Quigley said. “And this is why those pharmacies that do have a [body] scanning facility, where they do have a visiting scanning procedure of the lower leg … at least it gives you some sort of indication, which might mean that that person is advised to go off and a further hip scan or back scan to see how they’re travelling, followed up maybe six months down the track with another one. This is where pharmacists can play a big role.”
Another role for pharmacies, Mr Quigley says, is in empowering the patient and “helping them understand that this [osteoporosis] isn’t [necessarily] something that’s sudden” and that management will often include lifestyle considerations such as diet/nutrition, supplements and sensible weight-bearing exercise.
“It’s a matter of just gently getting involved in the conversation,” he said.
Professor Center agrees that pharmacies could play a key role in promoting public health messages around bone health, risk of fractures and osteoporosis.
“What often happens with a fracture,” she said, “is that people will go to a hospital, or wherever their fracture gets set in plaster – they may or may not need an operation – and then the next time they go to their GP is about something completely different. They’ve forgotten about their fracture – it’s ‘all fixed now’ – and so it never gets brought up. “[But] we know that … [only] somewhere between 20 and 30 per cent of people with low trauma fractures are treated appropriately for osteoporosis.”
So, there’s a “huge treatment gap” here, she says, and this is where pharmacies could play a vital role in providing education and raising awareness.
“Make people aware that osteoporosis is common,” she advised.
“Anyone who has had a [low trauma] fracture should consider themselves as having osteoporosis,” she continued. “So, even asking about that, asking about their family history – if someone’s on prednisone, if someone has diabetes, if someone has an overactive thyroid, if someone looks very underweight … then that’s something [pharmacists] can flag that they may be at risk, and something needs to be done.”
References
- healthybonesaustralia.org.au/wp-content/uploads/2020/11/Burden-of-Disease-Analysis-2012-2022.pdf
- mayoclinic.org/diseases-conditions/osteoporosis/symptoms-causes/syc-20351968
- healthybonesaustralia.org.au/your-bone-health/risk-factors/
This feature was originally published in the March issue of Retail Pharmacy magazine.
