After completing extensive background research regarding osteoporosis, its modifiable risk factors, treatment and debilitating consequences, it can be determined that the modifiable risk factors of this disease include sufficient calcium and vitamin D intake, consistent weight-bearing exercises, certain medications taken such as steroids, lifestyle factors such as regular smoking and alcohol intake and excess weight (obesity). Therefore, the risk factors that cannot be modified include gender, where females (particuarly post-menopausal women) are at a heightened risk, body build and various pre-exisiting medical conditions. As a result of osteoporosis, bone mineral density (BMD) becomes so depleted that the individual’s risk of fracture is substantially increased, which, if fracturing does occur, subsequent physical and psychological ramifications has an increased potential of occurence. These findings are supported by both the extensive background research conducted and is also discussed in the source analysis of a journal article below.
The journal article titled Clinician’s Guide to Prevention and Treatment of Osteoporosis was, as stated in the abstract, ‘developed by an expert committee of the National Osteoporosis Foundation (NOF) in collaboration with a multispecialty council of medical experts’. It was recently published online in the National Library of Medicine, which is operated by the US government, in 2014. The ‘council of medical experts’, as stated in the abstract, include Felicia Cosman, Suzanne Marie Jan de Beur, Meryl Leboff and Michael Leniecki (as the main contributors). Their respective qualifications are as follows;
- Cosman is a Professor of Clinical Medicine at the Columbia University College of Physicians and Surgeons.
- de Beur is an associate professor of Medicine at the John Hopkins School of Medicine.
- Dr Leboff is the Director of the Skeletal Health and Osteoporosis Centre and Bone Density Unit, located in Boston.
- Dr Leniecki is the Director of New Mexico Clinical Research and Osteoporosis Center as well as a Clinical Assistant Professor of Medicine at the University of New Mexico Health Sciences Center.
The main purpose of this credible journal article is to ‘offer concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis’. The journal article comprehensively covers the following areas;
Osteoporosis and Fractures:
The article states that ‘osteoporosis affects both sexes and all races, and its prevalence will increase as the population ages’, however, it is ‘preventable and treatable’. It characterises osteoporosis by low bone mass, deterioration of bone tissue and disruption of bone architecture, compromised bone strength and an increased risk of fracture, where the risk of fracture is highest in those with the lowest BMD. The most common fractures, according to the journal article, are of the vertebrae, proximal femur and distal forearm. All fractures have the potential to cause psychological symptoms and distress, ‘most notably depression and loss of self-esteem.’.
Prevention recommendations:
The article includes universal recommendations that aim to prevent the loss of bone mineral density (BMD) and consequently the development of osteoporosis. These recommendations include;
- A diet that includes adequate amounts of total calcium intake: 1000mg/day for males aged 50 to 70 and 1200mg/day for females over 50 and males over 70, where ‘lifelong adequate calcium intake is necessary for the acquisition of peak bone mass and subsequent maintenance of bone health.’.
- Adequate amount of vitamin D intake: around 800 to 1000 IU/day. This is because vitamin D ‘plays a major role in calcium absorption, bone health, muscle performance, balance and risk of falling.’.
- Regular weight-bearing and muscle-strengthening exercise, which can ‘improve agility, strength, posture and balance.’.
- The cessation of tobacco smoking and avoidance of excessive alcohol intake.
These modifiable lifestyle risk factors are supported by many reputable sources, such as Healthy Bones Australia, who state that calcium is the major building block for bones as bones store calcium, and when individuals do not get enough calcium in their diet, the body will use the calcium stored in their bones to fulfil other functions, resulting in porous bones if this calcium is not replaced. In addition to this, Healthy Bones Australia also emphasise the importance of weight-bearing exercise, resistance training, high impact exercise or balance training. They also state the importance of vitamin D, stating, ‘Vitamin D is essential to bone health. It increases the amount of calcium that’s absorbed from the gut, adjusts the amount of calcium that’s in the blood and strengthens the skeleton.’ (Healthy Bones Australia, 2021)
Diagnosis:
The article states that DEXA scans of the hip and spine are used to establish a diagnosis of osteoporosis, predict future fracture risk and monitor the disease in patients. The Radiological Society of North America support this, and also state that the individual’s information is collected and then converted into a T and Z score;
• T score measures the amount of bone the individual has in comparison to a normal population of younger individuals
• Z score measures the amount of bone you have in comparison to those in your age group
(RSNA, 2021). According to the journal article, peak bone mass is achieved in early adulthood, which then faces a steady decline in BMD. The rate of bone loss accelerates substantially in women during menopause, progressing at a slightly slower pace in postmenopausal women and in older men. BMD testing is ‘a vital component in the diagnosis and management of osteoporosis’ as it has been shown to ‘correlate with bone strength and is a predictor of future fracture risk’.
Pharmacological recommendations:
If individuals are diagnosed with osteoporosis, the article examines current pharmacologic treatment recommendations. It states that ‘current pharmacologic options for osteoporosis are bisphosphonates, calcitonin, and estrogen agonist/antagonist such as raloxifene, which according to the Mayo Clinic, mimics estrogen’s beneficial effects on bone density in postmenopausal women, without some of the risks associated with estrogen. (Mayo Clinic, 2020). However, the journal article emphasises that no pharmacologic therapy should be considered indefinite in duration and that there is no uniform recommendation that applies to all patients, meaning decisions regarding management treatments must be individualised. The journal article stresses that managing osteoporosis involves preventing consequences such as fractures. This is supported by the Osteoporosis and Related Bone Diseases National Resource Center, which outlined that the goal for managing osteoporosis is to slow the progression of the disease, including the depletion of bone density and bone loss, and prevent consequences or ramifications such as fractures. (Osteoporosis and Related Bone Diseases National Resource Center, 2019)
Bone Homeostasis:
According to the journal article, ‘the process of bone remodelling, which maintains a healthy skeleton, may be considered a preventative maintenance as it continually removes older bone and replaces it with new bone.’. Bone loss occurs when this continual cycle is disrupted in some way. This is supported by Tortora and Grabowski’s ‘Principles of Anatomy and Physiology’, which states that bone remodelling serves two purposes; It renews bone tissue before deterioration sets in and it redistributes bone matrix along lines of mechanical stress, as well as healing injured bones (Tortora & Grabowski, 1999). Figure 1 shows an architecturally weakened bone structure with significantly reduced mass as individual trabecular plates of bone are lost. Additionally, according to the 2015 journal article title Biology of Bone Tissue: Structure, Function, and Factors That Influence Bone Cells, published online by the National Library of Medicine, several studies have shown that oestrogen maintains bone homeostasis by inhibiting osteoblast and osteocyte apoptosis and preventing excessive bone resorption (Florencio-Silva, et al, 2015).
Figure 1: Micrographs of normal and osteoporotic bones to show the changes within the cancellous bone as a consequence of bone loss.
Steroids:
The article analyses that the use of steroids, such as glucocorticoids can decrease bone formation and cause bone loss, therefore reducing bone quality. This is supported by the Helen Hayes Rehabilitation Hospital, which states that almost one in three postmenopausal women who routinely take steroids will have a spine fracture and a person on steroids is more than twice as likely to have a spine fracture compared to a person not taking steroids (Helen Hayes Hospital, 2021) and is also supported by the 2020 journal article titled Efficacy and safety of 18 anti-osteoporotic drugs in the treatment of patients with osteoporosis caused by glucocorticoid, which states that the duration and dose of glucocorticoids can have a serious impact on the risk of fracture. (Liu, et al, 2020).
Risk Factors:
According to the journal article, ‘the more risk factors that are present, the greater risk there is of fracture.’. Many factors have been associated with an increased risk of osteoporosis-related fracture, examined in Table 2 and the risk for falling is examined in Table 3, as many osteoporosis-related fractures are a result of falls.
Table 1: Conditions, diseases and medications that cause or contribute to osteoporosis and fractures.
| Lifestyle factors | Alcohol abuse Frequent falling Inadequate physical activity Vitamin D insufficiency Excessive thinness High salt intake Low calcium intake Excess vitamin A Immobilisation Smoking (active or passive) |
| Genetic diseases | Cystic fibrosis Glycogen storage diseases Hypophosphatasia Osteogenesis imperfecta Riley-Day syndrome Ehler-Danlos Hemochromatosis Marfan syndrome Parental history of hip fracture Gaucher’s disease Homocystinuria Menkes steely hair syndrome Porphyria |
| Hypogondal states | Androgen insensitivity Hyperprolactinemia Anorexia nervosa Panhypopituitarism Athletic amenorrhea Premature menopause Turner’s and Klinefelter’s syndrome |
| Endocrine disorders | Central obesity Hyperparathyroidism Cushing’s syndrome Thyrotoxicosis Diabetes mellitus (types 1 and 2) |
| Gastrointestinal disorders | Celiac disease Inflammatory bowel disease Primary biliary cirrhosis Gastric bypass Malabsorption Gastrointestinal surgery Pancreatic disease |
| Hematologic disorders | Haemophilia Multiple myeloma Thalassemia Leukaemia and lymphomas Sickle cell disease Monoclonal gammopathies Systemic mastocytosis |
| Rheumatologic and autoimmune diseases | Ankylosing spondylitis Rheumatoid arthritis Systemic lupus Other rheumatic and autoimmune diseases |
| Neurological and musculoskeletal risk factors | Epilepsy Parkinson’s disease Multiple sclerosis Spinal cord injury Muscular dystrophy Stroke |
Table 2: Risk factors for falls
| Environmental risk factors | Lack of assistive devices in bathrooms Obstacles in the walking path Loose throw rugs Slippery conditions Low level lighting |
| Medical risk factors | Medications causing sedation (narcotic analgesics, anticonvulsants, psychotropics) Anxiety and agitation Orthostatic hypotension Arrhythmias Poor vision Dehydration Previous falls or fear of falling Depression Reduced problem solving or mental acuity and diminished cognitive skills Vitamin D insufficiency Urgent urinary incontinence Malnutrition |
| Neurological and musculoskeletal risk factors | Kyphosis Reduced proprioception Poor balance Weak muscles/sarcopenia Impaired transfer and mobility Deconditioning |
This journal article was written recently in 2014 by a panel of authors who have both credibility and authority in this topic due to their field of study and occupation. Additionally, it was developed by the National Osteoporosis Foundation and published in the National Library of Medicine, both respected and credible organisations. The purpose of this journal article is to inform individuals (eg; clinicians) about the treatment and prevention of osteoporosis, which therefore has direct relevance to my depth study topic. In addition to this, the information presented was highly accurate and has been validated by various credible sources, as seen throughout the analysis.
