Search for Answers About Osteoporosis : Cases of Crippling Bone Disease Expected to Rise as Baby Boomers Age

It seems everyone has an older relative with a broken hip, or has noticed with a sense of puzzlement that their parents seem to be shrinking.

Because these experiences are so universal there is the temptation to dismiss them as inevitable. But the fact is that osteoporosis, the disease of bone-thinning found mostly in the elderly, is a debilitating, expensive and sometimes almost fatal ailment that doctors are scrambling to prevent and treat in better ways.

Standing-Room-Only Conference

About 700 medical practitioners and scientists from around the world gathered at a standing-room-only conference on osteoporosis at the National Institutes of Health here last week. They discussed every aspect of the subject, and almost always, they argued.

Some facts that nobody challenged are that osteoporosis caused 247,000 hip fractures in 1985, and the total cost of treating such injuries was estimated to have been between $7 billion and $10 billion in 1986, according to conference co-chairman Dr. William Peck of the Jewish Hospital of St. Louis.

Osteoporosis is also the major cause of a pattern in the elderly--especially women--whose shoulders hunch forward as a result of deterioration in their spines, giving them the stooped appearance associated with extreme old age.

With life expectancy rising and the population rapidly aging, the incidence and financial costs of osteoporosis are expected to multiply rapidly and place an enormous burden on the already shaky American health system in the near future, especially when the ever-monitored baby boomers begin breaking hips in about 20 years.

More findings gathered from various conference presentations:

-- Of those who break their hips, only 25% will experience a full recovery. Half will need some assistance in carrying out their daily activities for the rest of their lives, and one-fourth will remain so disabled that they will need to be placed permanently in a nursing home.

-- More than 12%, and perhaps as many as 20%, of those who suffer hip fractures will die within a year of their injury. This does not mean that people die of hip fractures, but that such a long, painful and disabling illness experienced by older people may depress them and leave them more vulnerable to other ailments, such as heart failure.

-- Of those individuals who live to age 90, one-sixth of the men and one-third of the women will suffer a hip fracture.

One or More Fractures

Unpublished data from the Mayo Clinic in Rochester, Minn., Peck added, suggests that 4% of all women will have one or more fractures of the vertebra. Dr. L. Joseph Melton of the Mayo Clinic pointed out that while most hip fractures are the result of falling, vertebral fractures usually happen spontaneously--that is, during a time of little or no movement--in a person with osteoporosis.

The participants seemed to agree on only two things: that much more research needs to be funded in this area, and that the public needs to pay more attention to osteoporosis.

“This is not a consensus conference,” Peck said afterward. “We did not force ourselves to form a consensus on issues where none was possible.”

Dr. Maria Greenwald of the Osteoporosis Medical Center in Beverly Hills said: “The thing that struck me was that the same questions were asked over and over and over: When to use calcium, when to use estrogen, when do you screen? There’s a lot of confusion out there among physicians, as much as among lay people.”

While there are no easy answers, there are some things people of all ages can do to help prevent osteoporosis. These include regular exercising, not smoking, consuming no more than two alcoholic beverages a day, avoiding extreme thinness and including 1,000 milligrams of calcium in the diet per day.

There is controversy over how much and what kind of exercise is appropriate to prevent or minimize osteoporosis, with some studies pointing to load-bearing exercise having the best bone-building effect. Aerobic exercise is also thought to help, with activities that subject the skeleton to weight-like stress best. Swimming is the least relevant exercise but better than none at all, the experts agreed.

Because it is nearly impossible to set up studies that follow large numbers of people from their 20s into their 80s, doctors cannot conclusively state that taking supplements over a lifetime will prevent fractures. But, pressed on the subject, most doctors seem to agree it is probably a good idea to take a supplement.

“It is easy to recommend that 1,000 milligrams of calcium should be taken in each day for the entire population, and this can be achieved by dietary methods,” said Dr. Lawrence Riggs of the Mayo Clinic, chairman of the conference’s calcium panel. By dietary methods, Riggs meant eating foods high in calcium, such as leafy green vegetables, canned salmon, sardines with bones and dairy products. Drinking a quart of skim milk daily would provide 1,200 milligrams of calcium.

Taking Supplements

But there is a great deal of disagreement over whether anyone would routinely eat enough of these foods to fulfill his or her need for calcium, and Riggs added that for the many people considered to be at high risk, “it is reasonable to take supplements. They are safe and inexpensive.”

Since bone mass reaches its peak in young adulthood, some doctors recommended slightly higher doses, such as 1,200 milligrams, for adolescents to encourage the forming of as much bone as possible before the decline begins.

Anyone considering taking a daily supplement should first consult his or her doctor to be sure it is safe, and for advice on what kinds to try. A call to a doctor or center that specializes in osteoporosis may also help in determining which supplement to take. People who have had kidney stones should not take a supplement.

Those at high risk for osteoporosis may be the most interested in taking a supplement. Women are especially susceptible to bone-thinning after they go through menopause, because the resulting loss of estrogen, a hormone which had been produced to prepare for pregnancy, causes their bones to lose density. But loss is caused by many other factors, too, and occurs in some women before menopause, and even in some children.

At any age, women are twice as likely as men to have a hip fracture, according to Dr. Jennifer Kelsey of Columbia University in New York. Men are at lower risk because their bone mass is greater and they receive some continued protection from the male hormone testosterone, since they do not have a “menopause,” or drastic, sudden, mid-life change in their reproductive biology.

Dr. Steven Cummings of the University of California at San Francisco told the audience that the research gathered at his hospital, one of the leading osteoporosis departments on the West Coast, suggests that “10 to 20% of all hip fractures are attributable to smoking.” Among all women, he said, there is a 20 to 23% risk of having a hip fracture, but only 13% of non-smoking women are expected to break a hip.

Being white and being slender were considered “well established” high-risk factors by Dr. Robert B. Wallace of the University of Iowa, chairman of the risk factors panel. Blacks have greater bone density than whites, making blacks only half as likely to suffer fractures at comparable ages. The matter of where Americans of Asian descent figure in this equation is still being studied, although it was noted that the Japanese and Chinese are at lower risk than people who live in Western countries.

Bone-thinning is being treated in a variety of other ways, but most of these therapies are still in the infant or testing stages. Other methods discussed included a transdermal patch, much like a Band-Aid that releases estradiol into the body; calcitonin, fluoride, parathyroid hormone, anabolic steroids and others.

There was not much agreement on when to use the new screening methods that have just been developed in the last five years to detect osteoporosis. Mass screening was not recommended, according to Dr. C. Conrad Johnston Jr. of the University of Indiana, chairman of the panel on bone mass measurements.

But the panel thought the new tests, which cost about $150, “may be useful in selecting postmenopausal women for estrogen replacement therapy,” especially given the difficult nature of the patient’s decision regarding estrogen. Those who should be screened, Johnston said, included very high-risk patients, such as those with anorexia nervosa or amenorrhea, the cessation of menstrual periods in young women.

OSTEOPOROSISRISK FACTORSPhysicians frequently mention factors listed here as moderately or strongly related to the risk of contracting osteoporosis.

Factors That Decrease Risk

Black ethnicity

Use of estrogen

Regular exercise

Adequate calcium intake

Obesity *

* Doctors do not recommend obesity as a measure to prevent osteoporosis because it increases chances of heart disease and other serious illness.

Factors That Increase Risk Old age

Anglo ethnicity

Extreme thinness

Alcohol consumption

Cigarette smoking

Premenopausal removal of ovaries

Use of corticosteroids

Source: Risk Factors Panel at Research Directions in Osteoporosis Conference, Bethesda, MD, Feb. 9, 1987.