Inverting our approach to Osteoporosis
By Robert R. Zaid, D.O
Genesys Regional Medical Center
Osteoporosis is responsible for 1.5 million life altering fractures a year in the United States . Hip fractures are among the most debilitating fracture related to Osteoporosis and considerable resources are utilized in treating these patients. Typically, high risk patients who are post-menopausal women are screened for Osteoporosis and treatment is geared towards prevention of bone loss. Often patients are diagnosed too late and would have benefited from early intervention.
Peak bone formation in males and females occurs around 25 years of age , while women undergo accelerated bone loss at menopause. In fact, bone mass increases progressively during childhood and 40% of total bone mass is accumulated during late adolescence . Children are capable of extracting calcium out of their diets more efficiently than the elderly. This may cause us to rethink where the emphasis should be placed in treating Osteoporosis.
In considering treatment for Osteoporosis, primary prevention is as much if not more important than secondary or tertiary prevention. In other words, it is vital as family physicians to educate and promote good lifestyle choices to our youth while their bones are still forming and before bone loss begins.
In the United States, children have been replacing caffeinated drinks for dairy in their diets, playing video games instead of baseball and some children have begun smoking. All of these factors are contributing to decreased peak bone mass and studies have shown that bone mass in adolescents is related to risk of Osteoporosis later in life. We should emphasize bone formation early on than preserving bone later in life.
RISK FACTORS (modifiable)
If we are going to be successful in preventing osteoporosis, we must understand the risk factors, especially ones that we can alter. The modifiable risk factors for Osteoporosis can be divided into metabolic risk factors and mechanical risk factors.
Metabolic risk factors
Smoking, caffeine, and alcohol can all cause excretion of calcium from the urine. In addition, excessive intakes of protein and phosphate can cause a negative calcium balance1. Inadequate diet and low calcium intake early in life may result in a decreased peak bone mass . All of these factors are negligible if appropriate calcium intake or supplementation are implemented.
Increased consumption of soft drinks is replacing dairy drinks and this affects bone structure in many ways. These drinks will cause diuresis and loss of calcium from the urine, while providing high amounts of phosphates which also promote calcium loss in the urine. Finally, the absence of calcium rich dairy products only adds to the calcium deficiency.
Decreased exposure to the sun can decrease Vitamin D levels in the body which in turn can cause a decreased absorption of calcium in the blood. Parathyroid hormone then is secreted and bone loss occurs to maintain calcium levels . Over time this can have deleterious effects on bone structure and can cause thinning of cortical bone.
Mechanical risk factors
Although, bone metabolism relies on the total body calcium loads, bone formation depends on weight bearing exercise. Bone becomes stronger as demand and work increases. Low loads allow for bone maintenance, high loads cause bones to become stronger and very high loads are not good for bone. It is imperative that children exercise and run around and the trend towards video entertainment makes this more difficult to find balance.
As explained above, children are much better handlers of calcium than adults. Due to this fact, we will obtain better results for bone health if we encourage calcium consumption at an early rather than older age.
Current recommendations for calcium intake can be found in Table 2. Good sources of calcium can be found in yougurt, milk, cheese, sardines and salmon . If supplementation is needed, Calcium Citrate and Gluconate are more soluble than Calcium Carbonate. A more comprehensive list of foods rich in calcium can be found in Table 3.
Patient population Mg
Children <10 years 700
10-25 years 1300
Pregnant women 1500
Lactating women 2000
Table 2: Recommended daily calcium intake
Food Serving Size Calcium per Serving
Milk 1 cup 296 mg
Yogurt 1 cup 300 - 415 mg
Pudding 1 cup 250 mg
Ice cream 1 cup 236 mg
Cottage cheese (1%, low fat) 1 cup 120 mg
Cheddar cheese 1 ounce 213 mg
American cheese 1 ounce 198 mg
Turnip greens 250 mg
Collard greens 1 cup (cooked) 226 mg
White beans 1 cup (cooked) 200 mg
Mustard greens 1 cup (cooked) 125 mg
Broccoli 1 cup (cooked) 100 mg
Fortified cereals 1 cup 1000 mg
Fortified orange juice 1 cup 350 mg
Sardines (canned w/ bones) 3 ounces 275 mg
Tofu (processed w/ calcium sulfate) 3 ounces 225 mg
Salmon 3 ounces (+ bones) 180 mg
Table 3: Foods high in calcium (Adapted from Rhode Island Osteoporosis Foundation)
Vitamin D levels can be attained with sun exposure for 10-15 minutes a day without sunscreen. Dietary sources of Vitamin D can be found in liver, fish, Swiss cheese, egg yolk and fortified milk.
Amounts of caffeine should be limited and children should avoid soft drinks.
Weight bearing exercises can be performed fairly easy and does not require much effort. Some examples of appropriate exercises include walking, jogging and dancing. Bone is extremely sensitive to exercise and mechanical load. Low loads will maintain bone, while high loads will remodel bone to with-stand the new loads.
Osteoporosis is quite debilitating to our patients and to the cost of healthcare. Patients lose quality of life and have decreased function. As family physicians, we have a unique ability to examine our patients and promote lifestyle choices early on that may benefit them before it is too late.