A Feeling Deep in Your Bones
No matter what some of us may imagine, osteoporosis isn’t just a disease of a few frail white-haired ladies.
Also called brittle bone disease, it threatens more than 28 million Americans. Young and old. Men and women. About 10 million people have it, and an additional 18 million have the low bone mass that precedes it. Although osteoporosis is linked to a decline in the female hormone estrogen, about 20% of sufferers are men.
Results of an ongoing national study recently revealed that more than half of postmenopausal women older than 50 with no history of the disorder either had thinning bones or outright osteoporosis. Doctors warn that younger, weight-obsessed women who cut out milk, cheese and other sources of calcium are setting themselves up for a rude awakening before they reach their golden years.
“Half a bagel for breakfast, lettuce for lunch and just yogurt for dinner . . . can have significant repercussions on their health later,” cautions Dr. Aurelia Nattiv, director of the UCLA Osteoporosis Center.
Osteoporosis results in poor posture, pain and 1.5 million fractures annually. The bone tissue disorder occurs when older bone cells break down faster than they can be replaced with new bone.
Although white women were long considered at highest risk, the National Osteoporosis Risk Assessment study--the largest study of its kind to date--found low bone mass and osteoporosis among greater proportions of postmenopausal Asian, Latino and Native American women.
Think of bone mass as money in the bank. If you don’t make deposits and earn interest over the years, you can run short later. About 90% of peak bone mass is accumulated by age 18; adults hit their peak by age 30.
In growing numbers of teenagers and college athletes, excessive dieting is eroding the very bone they should be building for adulthood. Young dieters often skip foods needed to strengthen their skeletons. If they’re also sedentary, they’re missing bone-fortifying exercise.
At the other extreme--and at particular risk for early osteoporosis--are female athletes such as distance runners who have eating disorders or poor nutritional habits, and train to the point that their menstrual periods started late or have stopped prematurely, Nattiv says. As a UCLA team physician, she screens for signs of bone loss, such as stress fractures.
“We’ve seen women in their 20s that have bone density of women in their 50s, 60s and 70s. In some cases we’re . . . talking about real osteoporosis in a 20-year-old,” Nattiv said. Treatment choices are limited because many medications are not recommended for women of childbearing age. Nattiv advises them to train less intensely and eat a more balanced diet, including calcium. In some cases, she puts them on hormone therapy.
So if the numbers and risks of osteoporosis are so high among so many segments of the population, why is the disorder so underdiagnosed?
It boils down to this: Osteoporosis is a silent disease.
Few Warning Signs Before a Serious Break
Typically, sufferers may have no pain and no clue until they break a hip, snap a wrist or suffer tiny spinal fractures that sometimes leave them with a dowager’s hump or pare a few inches from their height. The breaks are complicated by the accelerated bone loss that comes with declining estrogen. Broken hips often initiate a downward spiral of lost mobility and illness, culminating in death. About 15% of white women will break hips, and the injury will prove fatal in 10% to 20% of those cases.
Broken bones got Judy Beth Dare’s attention.
The Walnut resident developed back pain in April, three months after a liver transplant. Although she was warned that the steroid prednisone in her post-transplant regimen wasn’t good for bones, she didn’t suspect osteoporosis.
Neither did doctors, said Dare, 57.
“Then they did an X-ray and found some of the vertebrae were fractured,” she said.
Her bones had weakened dangerously, and she began taking alendronate, marketed as Fosamax, which increases bone mass and reduces fractures. Ten months later, Dare is feeling fine.
She was fortunate enough to benefit from current wisdom. Early detection and lifestyle changes can halt bone loss before it progresses to osteoporosis. And drug treatment can reverse losses or, at the very least, stabilize bone mass.
Doctors hope the national study, which aims to measure bone density in 200,000 women, will improve understanding of the relationship between bone mass, disease and fractures. They also hope it will convince more primary-care doctors to test patients.
“Clearly, a very small percentage of women are being screened in the primary-care setting,” said Dr. Ethel Siris, director of the osteoporosis program at Columbia Presbyterian Medical Center in New York and the medical director of the study. “We have to make risk assessment for osteoporosis a routine part of care. We’ve got the diagnostic tools. We’ve got the drugs. We’ve got compelling data telling us this is a significant issue for aging women,” she said. “If you wait for somebody to fracture before you diagnose, it’s like waiting for somebody to have a stroke before treating high blood pressure.”
Doctors May Feel They Don’t Have Time to Test
Dr. Conrad Johnston, vice president of the National Osteoporosis Foundation and a professor at the Indiana University School of Medicine, worries that osteoporosis awareness is growing at a time when many doctors complain that financial pressures and paperwork are limiting the time they can spend with patients.
“Take a 75-year-old patient you’ve got 10 minutes with,” Johnston said. “You have six or eight diseases [to discuss]. You don’t want to worry about another one.”
Doctors use several painless techniques to determine in a matter of minutes whether the amount of bone is normal, low or osteoporotic. A test called DEXA (for dual energy X-ray absorptiometry) is generally considered the best test because it measures bone density at your hip and spine. While a DEXA test costs about $250, a test that gauges density in the forearm--but is less precise--costs only about $40.
Since a new federal law went into effect in July, Medicare has been required to pay for bone density tests for those who are older than 65 and Medicare-eligible. Coverage by other insurers varies.
Results are reported by a “T score,” which compares a value based on postmenopausal age with the average value for a young, normal adult woman. The degree to which bone density differs from that expected in the younger woman determines whether there is low bone mass or osteoporosis.
In the fall, the National Osteoporosis Foundation issued its first treatment and diagnosis guidelines, which recommended testing all women 65 and older, regardless of risk factors. Postmenopausal women with one or more risk factors for fracture should be tested, as should all postmenopausal women who have suffered broken bones, the foundation said.
“You need to know what your risk factors are for screening,” Nattiv said.
Some women may have multiple risks and not realize it.
Take Helene Karples, a slim, healthy 64-year-old insurance agent from Aventura, Fla.
In December, her doctor recommended a bone density test. But she considered herself active, wasn’t a smoker or drinker, and had remained 122 pounds for years. Karples never worried about brittle bones.
She dismissed the test as merely “the ‘in’ thing to do.”
“So I chuckled and went in not thinking I had it, but it came back that I did,” she recalled recently. Although she still has no outward signs, doctors advocate treatment because her spine and hip are fragile.
Her doctor recommended Fosamax, but other doctors felt familial heart problems made her a poor candidate. Her gynecologist prescribed Evista, the brand name for raloxifene, which shares some benefits of estrogen without increasing the risk of breast or uterine cancer.
She recently traveled to California and consulted with Nattiv, who recommended Evista.
“I’m very confused,” Karples said after Nattiv told her that Evista, like estrogen, slightly elevates the risk of blood clots. “All these medications have so many side effects.”
There are several approaches to choose from. Everyone should maximize bone density by getting sufficient calcium and vitamin D, exercising regularly, and avoiding smoking and heavy drinking. But once significant bone loss is diagnosed, calcium and vitamin D supplements can slow the depletion and reduce fractures.
Drug Treatments Have Differing Side Effects
As for medication, the FDA has approved:
* Estrogen replacement therapy, which is used for osteoporosis prevention and treatment. Estrogen slows the breakdown of bone and in some studies has slashed the incidence of fractures by about half. It works as long as a patient takes it. Although estrogen offers bone and cardiovascular benefits, women must weigh those against heightened cancer risks.
* Evista, which is a designer estrogen for prevention.
* Non-hormonal drugs, such as Fosamax, which is used for prevention and treatment. Fosamax acts somewhat like estrogen to inhibit the breakdown of older bone cells. Although patients sometimes complain of heartburn, mild gastrointestinal pain or upset stomach, doctors are divided about whether those are major problems.
* Calcitonin, which is given through injection or a nasal spray called Miacalcin. It prevents only spine fractures.
Researchers hope to develop drugs that stimulate bone formation. Sodium fluoride has been shown in human trials to increase bone density in the spine. In early research, a genetically engineered PTH--identical to the natural parathyroid hormone--appears to stimulate the production of new bone cells and increase bone mass.
For now, men are limited to non-hormonal medications to avert side effects like breast development. But for women, “there are so many categories of treatments, you ought to be able to get something for a given woman appropriate to her needs,” Siris said.
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Osteoporosis: A Checklist
Risk Factors
In addition to a poor diet, especially a low calcium intake, and low body weight, some of the factors that put you at risk of developing osteoporosis are:
Advanced age.
Being female.
Eating disorders.
Low body weight, thin or small-boned, or low body fat.
Family history of osteoporosis.
Estrogen deficiency, found in women with menstrual problems, those whose ovaries were removed and those whose estrogen drops before menopause.
Smoking and heavy drinking (which along with genetics are the primary factors in men)
Sedentary lifestyle or prolonged immobilization; lack of weight-bearing exercise
Prolonged use of certain steroid medications, such as cortisone taken by some people with asthama and rheumatoid arthritis. Use of anti-seizure drugs Dilantin and phenobarbital. Also, excessive use of thyroid hormone.
Metabolic diseases and gastrointestinal diseases in which the stomach doesn’t absorb important nutrients.
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Calcium: How Much Do You Need?
Optimal daily calcium intake for men, women and children as recommended by the National Institutes of Health.
Infants up to 6 months: 400 milligrams
Infants 6 to 12 months: 600milligrams
Children up to 10 years: 800-1,200 milligrams
Youngsters, young adults 11 to 24 years: 1,200-1,500 milligrams
Pregnant or lactating women: 1,200-1,500 milligrams
Premenopausal women age 25 to 50: 1,000 milligrams
Postmenopausal women 50 to 65 taking estrogen: 1,000 milligrams
Postmenopausal women 50 to 65 not taking estrogen 1,500 milligrams
Women over 65: 1,500 milligrams
Men 25 to 65: 1,000 milligrams
Men over 65: 1,500 milligrams
*
Sources
Dietary sources of calcium:
Collard greens (1 cup): 357 mg
Canned sardines (8 medium): 354 mg
Yogurt (8 ounces): 345 mg
Skim milk (1 cup): 303 mg
Calcium-fortified orange juice (1 cup): 300 mg
Spinach (1 cup): 245 mg
