Osteoporosis is a world health problem and is considered a pediatric disease with geriatric consequences. Primary prevention should start in the younger population with maximization of peak bone mass. Up to 90% of a person’s peak bone mass is achieved by late adolescence. Adolescents have the greatest potential for increasing their bone mass through lifestyle changes. Weight-bearing exercise during the prepubertal and early pubertal years can increase bone mineral content. Method: Randomized control studies have shown that weight-bearing exercise can increase bone mineral density in children and adolescents. A study of the skeletal response to increasing physical activity in adolescent boys revealed a 5 to 10 percent increase in bone mineral content in response to physical activity. High impact sports have been associated with greater gains in bone density. Nutrition is another lifestyle change that can improve bone mass. The strongest evidence is for calcium supplementation. During the trial period, the patient should be reevaluated with additional DEXA scans one to two years after initiation of treatment. If there is no improvement in bone mineral density, the antiresorptive agent should be discontinued and alternative treatment should be initiated. Randomized controlled studies of both alendronate and risedronate in glucocorticoid-induced osteoporosis in postmenopausal women have shown significant increases in bone mineral density and decreases in bone turnover markers. A third-generation bisphosphonate, Zoledronic acid, has shown to increase bone mineral density in the lumbar spine.
Definition of Poor Bone Density
Osteoporosis is defined clinically as a “systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk.” This is from a 2001 report by the National Osteoporosis Foundation. It roughly translates to the fact that with osteoporosis your bones become weakened and brittle and are at a much higher risk of fracture than normal bone. This is mostly due to the fact that the creation of new bone does not keep up with the removal of old bone. The inner bone structure becomes weak and porous, making it much less dense than healthy bone. This is what makes fractures from everyday activities more common, particularly in the hip, spine and wrist; all common areas for fracture with osteoporosis. This is the result of both cortical and trabecular bone losing mass and strength, which occurs due to various factors such as hormonal changes, deficiencies in calcium and vitamin D and various other causes.
Importance of Treating Poor Bone Density
Another reason not to ignore osteoporosis is the cost it incurs by not being managed adequately. It is essentially a waste of resources and money which would be effectively spent on treatment and prevention. Studies have shown that appropriate management using an osteoporosis drug leads to reduced incidence of fractures. Compared to the cost of medication, the cost of dealing with hip fractures (most osteoporosis drug regimes can reduce hip fractures by 40-50%) is huge and is usually to the detriment of the patient’s quality of life. Dealing with hip fractures can be both a short and long-term financial drain and places stress on health resources and carers, especially if the patient has lost independence. Similarly, fractures of the spine and other areas can also lead to long-term pain and disability and can have varied but often serious effects on a patient’s standard of living. By preventing fractures and disease progression in the first place, this is how cost-effective management with a focus on treatment of bone density can be.
Ignoring poor bone density can cause serious complications. Left untreated, those with osteopenia can progress to more serious osteoporosis, a significant cause for morbidity and mortality. Osteoporotic fractures are a major cause of disability and increased mortality in older patients, and the most common are fractures of the hip, spine, and wrist. Osteoporosis can cause devastating pain and discomfort, loss of mobility and independence, and often requires long-term nursing care. Furthermore, a hip fracture is a devastating injury, leading to decreased quality of life and survival, especially if the patient is elderly. Spine fractures are also associated with a decreased quality of life and increased mortality. Any fracture that occurs in the setting of osteoporosis can be very serious and can lead to death.
Non-Medical Treatment Options
Some patients with low bone density have a history of high-risk activities that can result in fractures, which have to be discouraged. Thus, consultation with the patient regarding what type of activity they used to do and how to modify it into a lower-risk form is needed.
Exercise is a critical aspect of preventing osteoporosis and managing bone density. Weight-bearing exercise or activities that force you to work against gravity, whether high or low impact, have a vertical force or loading pattern that will stimulate bone formation. High-impact activity shows increased bone density at the spine, whereas site-specific loading activity shows site-specific effects, thus all kinds of activity have benefits. Regularly scheduled exercise and sustaining these activities are crucial, as cessation of exercise will result in rapid bone loss. These exercise regimens require a patient to be assessed for their exercise capacity and to be educated about the right kind of exercise, with probable referral to a physiotherapist or exercise specialist in osteoporosis.
Diet has long been recognized as a risk factor for osteoporosis, with low calcium and vitamin D intake leading to decreased bone mass. Evidence shows that there is a positive role of specific nutrients and foods in enhancing skeletal health, beyond calcium and vitamin D. Several studies show that increased intake of fruits and vegetables is associated with higher bone mineral density. Recently, supplementation of fish oil has shown enhancement of bone density. Therefore, recommending a diet high in fruits and vegetables and adequate in protein and minerals, or specific nutrient supplements, might slow bone loss and reduce fracture risk in a more effective way compared to single vitamin or calcium supplementation.
Implementation of treatment for poor bone density is important. These approaches include dietary changes, exercise, and lifestyle modifications. These approaches can be used in patients with osteoporosis as prevention and as adjuvant therapy for medication and other high-risk interventions.
Dietary Changes
Diet can play a crucial role in the health of bones, and for this reason, improving calcium intake has been a focus for prevention and treatment. While the findings from calcium intervention trials have not shown a strong reduction in fracture risk, it is widely believed that obtaining adequate calcium from the diet helps in maintaining bone health. Dairy products are a rich source of calcium, and increased consumption can improve calcium intake. While some studies have shown an association between high dairy protein intake and increased fracture risk, it is believed that this may be confounded by other dietary factors, and that moderate consumption of dairy products plays a role in improving bone health. For the general population, dairy products and calcium-enriched plant-based milks or yogurts are an important source of calcium. However, for those who prefer to avoid these foods, it is worth noting that calcium-set tofu and some green vegetables such as broccoli and bok choy also contain moderate amounts of calcium. For the general population, it is recommended that to achieve adequate calcium intake, 3 servings of calcium-rich food should be consumed on a daily basis. It is important to keep in mind these targets are for maintaining bone health and they may differ for those who are seeking to optimize peak bone mass during adolescence or reduce calcium losses and fractures in the elderly. For those unable to obtain adequate calcium from their diet, calcium supplements may be of benefit.
Exercise and Physical Activity
In summary, both types of exercise, weight bearing and resistance, have a positive effect on bone density and can contribute to preventing osteoporosis and fractures. It is most beneficial for those of older age, who are at a higher risk due to bone loss from inactivity throughout their lifetime. Although it has been said that exercise can be the single most effective way to prevent osteoporosis, there is no sure way to tell how much increase in bone density will be enough to prevent fractures. But of course, any increase is better than none.
As for resistance type exercises and activities, these are beneficial in increasing bone density and preventing osteoporosis for all age groups. During the inactive years of adulthood and inactivity from aging, bone is being lost. By breaking the cycle of inactivity, this can be very beneficial to bone health. Research has shown that women who are postmenopausal can increase their bone density by performing strength training exercises. This can also benefit in preventing bone loss. Weight lifting is the most common resistance type exercise, but there are also many other activities that are considered beneficial to increasing bone density such as using weight machines, using free weights, and even using your own body weight. A study has shown that yoga can also be an effective way to increase bone density, this is especially so for postmenopausal women. It also helps reduce the risk of fractures by improving strength, flexibility, and balance. While golf and some forms of martial arts that involve striking and blocking techniques are also effective in improving bone density.
Exercise is probably the most influential lifestyle factor for bone density, yet it is the least studied. Bone is living tissue, thus it responds to exercise by becoming stronger. Just as a muscle, bone will grow stronger (and denser) in response to the force applied to it. The force that a physical activity places on a bone is known as the load. Weight bearing and resistance exercises are the only exercise related activities that will increase bone density. A weight bearing activity is defined as an activity that one does on your feet working your bones and muscles against gravity. After a study was done, results showed that men who regularly participate in sports that involve running have greater bone density in their spines than men who are less active. Jumping is an example of a high impact weight bearing exercise that also helps promote bone density. It has been said that postmenopausal women who participate in jumping activities can help prevent osteoporosis. Jogging is another high-impact exercise as well as dancing and aerobics. All of which are the most beneficial for the hip and spine areas which are very common sites for fractures due to osteoporosis. High impact weight bearing aerobics or jogging has been shown to increase bone density, and can also slow bone loss. An best for children during these developmental years to increase peak bone mass.
Lifestyle Modifications
Lifestyle changes can help to prevent or control many of the factors that contribute to bone loss. Diet and exercise have been mentioned and are the two most important components to maintain healthy bones. Smoking is detrimental to bone health and fracture risk, and it is important for individuals to develop a plan to quit smoking. With regards to alcohol, although there may be an increased risk of fracture at higher intakes, moderate alcohol consumption does not seem to affect bone density and actually may be beneficial to overall health. High intakes of vitamin A have been associated with reduced bone mineral density in some studies, but it is not clear if this is an independent effect. Finally, people should be aware of the medications that can cause bone loss (e.g., glucocorticoids, anticonvulsants) and discuss the potential risks and alternative treatments with their physician.
People should also be made aware that certain daily activities may increase the risk of bone loss and fractures because they cause a significant amount of bone breakdown. For example, excessive intake of alcohol has been linked to an increase in fractures. This is because alcohol has been shown to interfere with the balance of calcium in the body. Chronic use of loop diuretics (water pills) and too much salt can increase the amount of calcium excreted from the body. People who are on these medications or have a high salt intake should be aware of this and discuss with their physician how to maintain a good calcium balance. Caffeine also increases calcium loss and may double the amount of calcium lost in the urine. High caffeine intake is associated with an increased rate of bone loss. A recommendation for caffeine consumption to help protect bone health is to ensure a daily intake of no more than three cups of coffee a day (providing 300 mg of caffeine).
Medical Treatment Options
Hormone replacement therapy (HRT) is suggested as an option for primary prevention of osteoporosis for women under the age of 60. The potential risks and benefits of HRT should also be considered when treating postmenopausal women, aged 60-70, and treatment should be individualized. An estrogen deficiency state is the major cause of postmenopausal osteoporosis, and fracture reduction is coincident with prevention of bone loss. However, with growing concern of the side effects of prolonged HRT, Osteoporosis Canada has suggested limiting the use of HRT for treatment to women younger than age 60 and for a duration of no more than 5 years. Due to decreased use of HRT because of the potential risk and a now older population of women, HRT is no longer a prevalent treatment for osteoporosis.
Osteoporosis Canada developed clinical practice guidelines for the selection of men and postmenopausal women. A new treatment algorithm has also been developed for this group of patients to maximize benefits and minimize the risk of side effects. The major advances in the treatment of osteoporosis involve the use of antiresorptives. These medications increase BMD and reduce fracture risk by slowing or stopping the rate of bone loss above and beyond what occurs at the time of menopause, or a decrease in bone mass following androgen deprivation therapy or transplantation. Major antiresorptive drugs in use currently include estrogen replacement therapy, alendronate, risedronate, and more recently, intravenous zoledronic acid. Calcitonin is another option, with weaker effects demonstrated on the preservation of BMD and prevention of fractures. Estrogen replacement therapy is no longer first line therapy for osteoporosis, the cardiovascular side effects and increased risk of breast cancer have led to its demotion in the hierarchy of treatment. Although antiresorptive therapy is effective for increasing BMD and reducing fractures, a major limitation is the expense and/or inconvenience, as well as the potential side effects of medications, which have led to poor adherence and persistence of these drugs.
Medications for Improving Bone Density
Selective estrogen receptor modulators (SERMs): Raloxifene is the only available SERM in Australia approved for prevention and treatment of postmenopausal osteoporosis. Raloxifene has shown to preserve bone mass and decrease the incidence of vertebral fracture. It has no effect on the incidence of non-vertebral or hip fractures. Raloxifene also decreases LDL cholesterol and may be beneficial for postmenopausal women who have a significant risk of coronary heart disease but a contraindication to hormone therapy.
Bisphosphonates: This is the first-line treatment for intestinal and oral forms of osteoporosis. Bisphosphonates maintain or improve BMD over 3-5 years, depending on the drug, and decrease fracture incidence. They are generally well tolerated. Alendronate, etidronate, risedronate, and ibandronate are examples of bisphosphonates. Alendronate is administered as a once-weekly oral dose. Ibandronate is administered as an intravenous infusion and may be beneficial for patients with gastrointestinal malabsorption. Intravenous bisphosphonate treatment is not currently subsidized by the PBS for osteoporosis therapy.
Hormone Replacement Therapy
Hormone replacement therapy (HRT) is traditionally used to prevent the onset of osteoporosis in postmenopausal women. This is achieved through the introduction of estrogen and progesterone or solely estrogen into the body in an attempt to restore the hormone levels to those seen before menopause and thereby prevent bone loss. More recently, a group of drugs called SERMs (Selective Estrogen Receptor Modulators) has been developed, which act in a similar way to estrogen, by binding to the estrogen receptor, however, the effects on the breast and uterus are different. Although an effective way of increasing bone density, HRT is associated with a number of health risks, such as breast cancer, endometrial cancer, stroke, and deep vein thrombosis. Moreover, there are also problems with the method of delivery, as the most successful form of HRT is a patch, which some women find irritating to the skin. Due to the associated risks, some women choose not to undergo HRT, and for those with a history of breast cancer, it is contraindicated. HRT has also been proven to be effective in increasing bone density in men. A study by Orwoll, E., et al (2000) showed that alendronate, a drug used commonly in the treatment of osteoporosis, was less effective in men than in postmenopausal women. This suggests that more research is needed into osteoporosis in men, to find alternative methods of treatment. Step up to HRT has shown to decrease the rate of bone mass loss, and in a six-month study, testosterone replacement has resulted in a small increase in bone density.
Surgical Interventions
Surgical intervention is the very last option available to the patient when bone density is so low that the risk of osteoporosis is extremely high. There are two types of surgical intervention for osteoporosis patients. The first is spinal fusion. This is a procedure more commonly used for those with a slipped disc in the spine. This is where one of the discs in the vertebrae has moved out of place, so it is pressing on a nerve. Spinal fusion is used to help relieve the symptoms of nerve damage to the patient. But it is not solely for slipped discs, the procedure can be used to stabilize the spine in a patient with fractured vertebrae from osteoporosis. The way this is done is by using bone graft from the patient’s pelvis and placing it between the fractured vertebrae. This will help fuse the bones together and prevent any further movement which could potentially cause injury to the spinal cord. This will have the effect of reducing pain of the damaged vertebrae by preventing it from moving, which is the source of pain, and also preventing the possibility of spinal injury by further collapse of the vertebrae. The other method of surgery is joint replacement. This method is more commonly known to patients with osteoarthritis or rheumatism. It is a procedure which involves removing the damaged joint, which is the source of pain, usually the hip or knee, and replacing it with an artificial one made of a material such as stainless steel or titanium, and special plastic. This is a method to relieve pain and improve mobility of the patient, and although patients with osteoporosis-related fracture or joint damage are less likely to have it than those with arthritis, it is still an option for those with severe damage and the risk of fracture is high. High success rates of artificial joint replacements, ongoing developments in material and design of the joints, are a positive factor, and the method is something which would vastly improve the quality of life of the patient.
Finding Doctors Specializing in Osteoporosis
Choosing the doctors specializing in osteoporosis near me with the adequate experience and training in treating osteoporosis is the first step to optimal care. The healthcare provider should be willing and able to monitor your disease status and management of osteoporosis over time. If a person has a healthcare provider who has a doubt regarding knowledge of the status or management of osteoporosis, it may be inquired if your healthcare provider would consider a consultation with a physician whose practice is solely in the diagnosis and treatment of osteoporosis. Ask if the healthcare provider was referring to a physician who specializes in osteoporosis in your community.
Several different kinds of doctors can diagnose and treat osteoporosis. Some doctors have expertise in diagnosing the disease and working with patients to prevent fractures, while others are specialists in treating fractures. Surgeons are orthopedic specialists who treat fractures and other bone problems. Rheumatologists often diagnose and treat an early stage of the disease called osteopenia, as well as full-blown osteoporosis. Some internists, general practitioners, and family doctors are trained to treat osteoporosis and have experience treating patients with this disease. The healthcare provider who is the most familiar with a person’s medical conditions and the one who is to make the determination. Other considerations are who has available recommending treatments and specialist knowledge grounded in education and treatment with a particular osteoporosis medication, can be the best choice.
Importance of Consulting a Specialist
Before considering where to find a doctor for osteoporosis, it is important to understand why a specialist may be preferred over your primary care doctor. Osteoporosis is a very serious condition that frequently goes undiagnosed and undertreated. Studies show that not only is this condition four times more prevalent than heart disease among women, but it is also more likely to cause a 70-year-old woman to be admitted to a hospital for hip fracture than to develop breast, ovarian, and uterine cancer combined. This is not to say that your primary care physician cannot help you manage your osteoporosis. In many cases, they are very capable, especially if they assist you in being proactive by reading up on the disease and exploring various treatment options with you. However, osteoporosis specialists (rheumatologist or endocrinologist) are generally more familiar with the disease and up to date on treatments and testing options. An online journal by Health Services Research found that a surprising number of patients with serious medical problems did not see a specialist or even know that they had a choice. Oddly enough, insurance coverage made little difference in these results. Their study concluded that whether or not a person saw a specialist was more reliant on the patient’s knowledge about their medical condition and the specialist’s role in treating it. This implies that you, the patient, must take the first step in being your own health care advocate. The decision to see a specialist should not make you feel like you are abandoning your primary care physician, after all a specialist’s consultation can help to better inform your doctor on the best management strategies for your condition. Instead, you should see a specialist as an added resource and ally in your health care journey, who possesses information that may not be all too familiar to your primary care doctor.
Online Directories and Search Engines
Online medical directories and directories are among the tools that are helping consumers find medical specialists who have the very best qualifications to meet their needs. There are different directories available. Some directories are put together by corporations looking to steer consumers to their websites or the websites of their associates. Some of those directories are not publicized; insurance companies and employers might use such directories to recommend a select group of providers to their plan members. Other directories are publicized to consumers. These are often searchable databases that allow customers to find providers based on criteria such as location and medical specialty. Despite concerns of bias, a study suggests that most customers are interested in using this type of information to locate physicians. At this writing, information on the quality of these various types of directories is limited. However, as discussed below (see Section 11), customers should be able to identify a physician who is best qualified to meet their needs from unbiased, comprehensive information about physician qualifications and practice. Currently, some medical boards provide information on their websites about whether physicians have had any major professional disciplinary actions, and some directories include this information. However, it will be especially important to find ways to integrate meaningful information about doctor quality into the directories designed to guide consumer choices.
Referrals from Primary Care Physicians
Without a doubt, primary care physicians play an important role in initiating referrals to osteoporosis specialists, particularly with the existence of the healthcare environment in the United States. The US is predominantly a system of specialist care that is initiated by a referral from a generalist. PCPs are the “gatekeepers” to various specialists and often the patients’ access to specialists is directly dependent on a referral from their PCP. The study revealed that 70.6% of PCPs had referred a patient with osteoporosis to a specialist at some point, and 30% of PCPs reported that they had referred at least one patient in the last 6 months. The most commonly cited reasons for not making a referral were that the PCP was capable of managing the patient’s condition as well as or better than a specialist and the patient’s insurance would not cover a specialist.
The article is a report of a cross-sectional, mail survey conducted in 2006 from a random sample of 1000 PCPs who were members of the American Medical Association. In the survey, 586 PCPs indicated they were the ones who encountered patients who had taken bisphosphonates or took care of postmenopausal women with osteopenia or osteoporosis. The mail survey included a comprehensive series of questions that assessed referral patterns for patients to specialists, as well as perceived factors that might influence referral decisions. PCPs were asked to consider the last 5 patients with osteoporosis or low bone density that they encountered. It is unclear whether these specific patient encounters were the only ones considered while answering the survey questions or if other similar patients were taken into account.
Doctors rely on various professionals to help care for their patients. Overwhelmingly, referrals to specialists come from primary care physicians. Referral patterns to specialists were recently surveyed in a national random sample of office-based primary care physicians. Data were obtained from the National Ambulatory Medical Care Survey, conducted by the National Center for Health Statistics in 2004. Osteoporosis is believed to be under-diagnosed and under-treated by primary care physicians, largely because it is a silent disease with consequences that are in the distant future. In a study published in the journal Osteoporosis International, the investigators aimed to assess the referral patterns to osteoporosis specialists from PCPs, the impact of the osteoporosis specialists’ recommendations on the management of their patients with osteoporosis, and the perceived factors that influence referral decisions.
