As I sit down to write this latest article about osteoporosis, I realize that it is actually World Osteoporosis Day, a day that every year, the international campaign is observed to raise awareness about osteoporosis, its causes, symptoms, prevention and treatment. The aim is to instil in both patients and doctors the need to be diligent in educating and initiating measures to prevent progression of this condition and reducing fractures associated with the disease.
Osteoporosis is a common medical problem caused by the loss of bone mineral density. It is most often recognized in aging adults wherein the loss of density causes a weakening of bone and increased risk of fracture. It occurs without symptoms until diagnosed as a result of a fracture or through medical imaging. The fractures occur most often in the spine, hip, shoulder and wrist and are called fragility fractures due to weakening of the bone. Recommended screening in diagnosing and initiating recommended preventive measures and treatment in certain groups is important to reduce this risk.
Are you at risk?
Health Canada estimates that one in four women and one in eight men over the age of 50 have osteoporosis. Wrist, spine and hip fractures are most commonly associated with osteoporosis. In the senior population, fewer than half of those suffering a hip fracture will ever experience full functional recovery. In addition to age and gender, other risk factors include vitamin D and calcium deficiency, low body weight, family history of osteoporosis, smoking, excessive caffeine and alcohol consumption and long-term use of cortisone or prednisone.
This article is timely in that the Canadian Medical Association Journal has just recently published a report by the Canadian Task Force on Preventive Health Care on Recommendations on screening for primary prevention of fragility fractures, as well as a 2023 update by Osteoporosis Canada on Clinical practice guideline for management of osteoporosis and fracture prevention in Canada.
Who should be screened?
These guidelines are published for doctors to follow in assessing risk and identifying who should undergo screening tests and treatment protocols. Risk is assessed by a set of specific questions (FRAX) that determines personal details such as age, gender, height and weight, medication history, smoking and alcohol history, and family history, etc., all of which are then used to determine who is at higher risk for the disease and should be investigated. There is some variation between various guidelines, however, generally in Canada there is agreement that unless there are significant risk factors, first screening using the FRAX tool is only indicated for females 65 years and older and not for males. For both males and females, history of a previous fracture of the vertebra or the hip and more than one fracture, indicates high risk for future fractures and screening and possible treatment should be done.
Fractures of the vertebra can occur without one’s knowledge. After the age of 50, it is important to measure your height annually to detect any significant loss. A loss of more than two-and-a-half inches could be a clue that a spinal fracture may have occurred. A spinal X-ray should be done.
The most common method of screening for those who have been determined to be at risk is the bone mineral density (BMD) test. The instrument used measures the density or thickness of bone and the amount of mineral (calcium) in specific bones in the body, and indicates if osteoporosis is present.
Treatment and Prevention
Once the diagnosis is confirmed, various treatment options will be considered depending on the patient’s age, past and present medical conditions and degree of osteoporosis. The drugs currently available are used to reduce fractures of the hip and vertebra in both males and females. Evidence shows a significant reduction of these fractures in a three-year followup compared to a similar group of persons with no treatment. Specific drugs are used to treat the condition, often by a specialist, and careful monitoring of their impact on the patient is necessary.
Since the major effect of osteoporosis is the risk of a fragility fracture, keeping “in shape” physically is important. The advice for those with osteoporosis is good advice for all of us who want to avoid fractures. All types of regular exercise should be done, dependent on health status and previous fracture history. Balance, muscle strengthening and functional exercises which improve ability to perform everyday tasks should be routinely performed. Organized activity such as tai chi, group exercises and appropriate sports activities can improve balance and maintain muscle strength. As recommended by Osteoporosis Canada, when available, seek advice from exercise professionals who have training in osteoporosis for exercise selection, intensity and progression, especially after recent fracture or if there is high risk of fracture. Routine walking is recommended especially for older adults and improves a number of health conditions, but the effect on risk of fracture in patients with osteoporosis is uncertain.
Diet and fracture risk has been studied in great depth over the years. For those following a well-balanced diet, there is little evidence that taking supplementary calcium and vitamin D will reduce the risk of fractures. Nevertheless, most physicians recommend a 400-1,000 IU daily supplementation of vitamin D. There is no indication for supplementary vitamin K, protein or magnesium for those who consume normal diets.
In the present situation in Canada, the routine assessment for osteoporosis for vulnerable patients is often deficient. In addition to the millions of Canadians who have no regular family doctor and are not screened when indicated, there are many under the care of a physician or primary care provider who are not screened. For all of us, it is important that we take charge of our health care and seek the recommended screening tests when indicated. These could include laboratory blood tests, chest X-ray, mammography, kidney function tests, colorectal cancer screening or others according to our age, medical conditions and recommended guidelines. Osteoporosis Canada states that fewer than 20% of fracture patients in Canada currently undergo diagnosis or adequate treatment for osteoporosis. Be mindful of guidelines for this and any other conditions that you have, or for which you are at risk and be sure to get the appropriate assessments done.