16 ■ JANUARY 18, 2013
HEALTHCARE DIRECTORY: A SPECIAL ADVERTISING SUPPLEMENT
THE BERMUDA SUN
Over 50s susceptible to osteoporosis BY DR ANNABEL FOUNTAIN Osteoporosis is a major public health issue but tends to be under-recognized and under-treated. According to figures from the US, nearly 50 per cent of women and 20 per cent of men over 50 will suffer a fracture due to osteoporosis. So what is osteoporosis? It is a condition which makes your bones weak, leading them to break more easily. People with the condition sometimes break a bone just by falling at home. But this can be serious, especially if they break a hip. Some people only learn they have osteoporosis after they break a bone during a fall or mild impact, or if they lose height as a result of bones in their spine collapsing. Healthy bones should not break easily, and so these injuries are called ‘fragility fractures’. Some people have an increased risk of osteoporosis. They include: smokers; post-menopausal women, people who have taken steroids or other medications for prolonged periods (some anti-epileptic drugs, Heparin, Prednisone, Vitamin A); those underweight or malnourished; people with endocrine disorders such as an overactive thyroid or over-replacement with the thyroid hormone; and men with testosterone deficiency. You can’t change some risk factors such as age, sex, race and family history, but to reduce risk of fracture, diagnosis and early treatment is key. You can be tested for osteoporosis with a special X-ray, the DXA scan, which measures bone density You can also keep your bones as healthy as possible by following a diet with enough calcium and vitamin D, which are essential for bone formation and maintenance. Men and pre-menopausal women should have at least 1,000 milligrams of calcium per day (from foods, beverages or supplements). Post-
menopausal women need more and should have 1,200 milligrams of calcium per day. Sources of calcium include: milk, yoghurt, orange juice, tofu; cheese, cottage cheese, ice cream/ frozen yoghurt, soy milk; beans; dark, leafy vegetables, almonds, and oranges. The Institute of Medicine recommends that men over 70 and post-menopausal women need 800 IU of vitamin D each day. Children and healthy adults should have 600 IU per day, up to age 70. Vitamin D is manufactured by our skin when it is exposed to sunlight, or eaten as part of our diet. If you sit in the midday sun for 15 to 20 minutes a day, you will make 1,000 IU of vitamin D. In the winter, particularly in the northern hemisphere, vitamin D supplements are an alternative. The pigments in darker skin act as a sunscreen, so this skin makes less vitamin D.
Vitamin D deficient Even though we are in sunny Bermuda, people who do not tend to spend time outside, such as the elderly, or who wear high factor sunscreen may be vitamin D deficient. A 2010 study in Nutrition Journal found that 42 per cent of adults in the US were Vitamin D deficient. The highest rates were among African Americans and Hispanics. Exercise also improves bone mass in younger women and will maintain bone density and increase its strength after menopause. Physical activity also reduces the risk of falling and hip fracture in older women. You should exercise for at least 30 minutes, three times a week. The National Osteoporosis Foundation (NOF) recommends medication to treat post-menopausal women and men over 50 with a history of hip or
vertebral fracture. Drug therapy may also be recommended if you have an estimated 10-year risk of hip fracture greater than 3 per cent, or osteoporosisrelated fracture greater than 20 per cent. Your physician can calculate the absolute risk of fracture using the World Health Organization FRAX calculator, at www.shef. ac.uk/FRAX.
Treatment Osteoporosis medications reduce bone loss, increase/ maintain bone density and reduce the chance you will break a bone. You also need to take calcium and vitamin D for the medicines to work. Most people being treated for osteoporosis take bisphosphonates first. They slow the breakdown of bone and come in pill or a shot form. To avoid throat or stomach irritation, if you take them orally then take the pill in the morning on an empty stomach with eight ounces of water. Do not eat or drink anything else for at least 30 minutes. Avoid lying down for 30 minutes after taking it. Raloxifene (Evista) and Tamoxifen are Selective Estrogen Receptor Modulators (SERMs). SERMs have oestrogen-like effects on the bone and protect against post-menopausal bone loss. They also decrease the risk of breast cancer in high-risk women. They may not be as effective as bisphosphonates or HRT and are not recommended for pre-menopausal women. Hormone replacement therapy (HRT) is taken by some women to replace estrogen and progesterone, which are lost through menopause and which protect against osteoporosis. HRT is also useful for women who cannot take other osteoporosis medicine. It is a useful prevention for younger women with premature menopause (due to surgeries, cancer
treatment or other causes). Overall, HRT is not recommended for osteoporosis in post-menopausal women, but some women with persistent menopausal symptoms and those who cannot tolerate other types of osteoporosis treatment still use it. Another treatment is synthetic calcitonin — a hormone which regulates calcium in the body and which is good for pain relief for vertebral fractures. Parathyroid hormone (PTH) is from the parathyroid glands and high doses of the synthetic hormone (Forteo) stimulate the body to make new bone. It is not recommended for pre-menopausal women. Denosumab (Prolia) is a new medicine, given as an injection every six months. It is currently reserved for individuals who cannot take other osteoporosis medications, or who have severe osteoporosis which the usual medications fail to work on. Osteoporosis causes bones to become abnormally weak and easily broken. It can be treated and prevented with diet, exercise, not smoking, regular exercise and calcium and vitamin D supplements. If you’re not getting enough calcium and vitamin D from your diet, it is recommended that you take supplements. There are several medications that help to prevent osteoporosis in women after menopause. Bisphosphonates are the most recommended therapies. There are other options for patients who are intolerant of or unresponsive to bisphosphonates. Your doctor may arrange follow-up tests to monitor how the bones respond to your osteoporosis treatment. This may include a bone density scan (DXA) or laboratory tests. ■
DR ANNABEL FOUNTAIN is director of endocrinology, Bermuda Hospitals Board.