Our skeletons provide support, mobility, armor, and a storehouse for minerals. Driven by growth, genetics, hormones, stresses, nutrition, and mineral deposition and withdrawal, bones are continuously replaced every decade or so even in adults. Unhealthy bones can fail at any of their functions, with fractures having the most important consequence since they can result in disability and even premature death. Without proper nutrition or load-bearing activity (or with smoking or heavy drinking), bone mass and strength decline, and often the first warning of osteoporosis -- porous, honeycombed, brittle bones -- is a fracture a healthy bone wouldn’t have incurred with the same trauma.
Each year about 1.5 million people suffer an osteoporosis-related fracture, many of which lead to a downward spiral in physical and mental health. Half of women over 50 will have an osteoporosis-related fracture in their lifetime, with risk of fracture increasing with age. Mortality increases by 300-400% among hip fracture patients within 3 months after the fracture, and 20 percent of senior citizens who suffer a hip fracture die within a year. Many fracture victims become isolated and depressed, paralyzed by the fear of falls and additional fractures. Spine fractures are especially tough to diagnose and treat, yet are often our first realization that we have osteoporosis unless our primary care physician is far more aware than most doctors about bone health.
Unless we patients, our doctors, and the whole medical profession change our acts, our aging population, lazier lifestyles, and junk food diets will lead to half of Americans over the age of 50 having osteoporosis or being at high risk for it by 2020 and our hip fracture incidence doubling or tripling by 2040. [I’ll bet today’s youth’s electronic lifestyle and horrible diet will compound the picture dramatically.]
When a kid falls out of a tree and suffers a routine fracture, it hurts for a few days, then gives way to increased attention, a few autographs, some itching, a really neat smell, and maybe a missed sports season. It’s a symptom of juvenile judgment or overzealousness, not poor health. They fuhgheddaboutit and move on.
When a man stands on the toilet lid and the lid breaks, letting his full weight shove his ankle ‘round the bend (it really happened), the fracture will heal more slowly, and the months of limping may induce other musculoskeletal problems. The hassle is much greater, the extra attention is less fun, the complications can last for many months, but it ultimately heals and it portends nothing.
But when a senior citizen breaks a rib sneezing or bumping into a countertop, or his/her back starts forming a pronounced “S” rather than a marine’s “I” or a civilian’s slight “S”, a whole new, fragile, high-risk, potentially shortened phase of life has begun. Osteoporosis has bared its ugly teeth, and at this stage it’s tough to reverse the decline in health it causes. Little old ladies’ humped backs are not just cosmetic, not just about pain; they are proof of a very serious health problem that we can prevent as kids, delay as young adults, but only try to mitigate as we approach retirement age. It is far easier to prevent or delay than to reverse, so let’s examine some bone health facts and options and hope we can reduce its threat to our families.
Medical science has learned a great deal about bone health in just the past generation. Large trials have proven the incidence of fractures is reduced by vitamin D, calcium, physical activity at all ages, and certain meds when necessary. Falls are now recognized as a leading trigger of fractures, and much has been learned about preventing falls, especially in the aged population (that’s the insulting PC word for old people, used in their presence as though we don’t know the difference). Enhanced knowledge about why people fall has led to interventions that target the risk factors for falls, such as avoiding or minimizing use of medications that cause dizziness, modifying our homes, and training to improve strength and balance. The importance of bone health formation and maintenance from birth to death is now well understood. Non-invasive bone density and bone mass measuring instruments are among the most significant advances in the last quarter century, allowing doctors to assess an individual’s potential for bone disease and achieve preventive treatment now rather than corrective treatment after a fracture reveals the problem. There are effective treatments not only for osteoporosis, but also for other bone diseases such as Paget’s disease, hyperparathyroidism, rickets, and osteomalacia.
But all this new knowledge hasn’t solved what may be the biggest bone health threat: the limited awareness of bone disease and its treatment among health care professionals and the general public. Studies show that physicians frequently fail to diagnose and treat osteoporosis, even in elderly patients who have suffered an unwarranted fracture. One large study revealed that fewer than a quarter of hip fracture patients were tested for bone density or given calcium and vitamin D supplements and fewer than a tenth were treated with effective bone-strengthening drugs. What little systemic treatment is given often ignores proven protocol, and many patients and doctors still incorrectly think osteoporosis and its related fractures are a threat only for old white ladies.
There are three life phases, three means, and three resources for prolonging our skeletal systems. The phases are 1) building strong bones from infancy through adolescence, 2) preventing their decay into retirement age, and ultimately 3) renewing bones that have already weakened. The best means by far are building and maintaining strong bones through 1) physical activity and 2) diet, with 3) medication a distant third. And the available resources are 1) the government (to disseminate the new information), 2) health professionals (to implement it), and 3) the public (to learn it and force their providers to learn and apply it). This is where you come in, with the help of the Surgeon General’s report it’s based on, referenced below.
Physical activity, calcium, and vitamin D are vital to bone health throughout life, and most people are deficient in all three. Activity helps to increase or preserve bone mass and to reduce the risk of falling. All types of physical activity can contribute to bone health, in different ways. Being underweight or losing weight too rapidly without rigorous diet and vigorous activity increases the risk of fracture and bone loss. Falls can be reduced by muscle strengthening and balance training, professional home hazard reduction, and reduced psychotropic medications. Amenorrhea (cessation of menstrual periods) before menopause is a very serious threat to bone health and needs to be treated professionally promptly. Some medical conditions and prescriptions can affect bone.
Your doctor should be aware of the numerous “red flags” for the many bone diseases, because early identification can be critical to effective treatment and injury prevention. Testing should be performed on any patient for whom risk factor analysis indicates a strong potential for osteoporosis. Formal guidelines now exist for bone mineral density (BMD) testing in women over age 65, younger women with multiple risk factors, and anyone with fragility fractures or other diseases or medications that risk fracture. Individuals, particularly men and premenopausal women with a fragility fracture or diagnosed with osteoporosis, should be assessed for treatable causes of the disease.
Much more information on all these topics appears in the Surgeon General’s bone health website, clearly written for readers like you and me in both text and outline form. It demonstrates the Surgeon General’s concern for this topic and his interest in making sure we and the health care world understand it. Its main messages for us are:
- Educate yourself, your family, and your doctor on the penalties of ignoring this threat.
- Begin developing your kids’ bone strength at birth and keep at it until they are adults willing and able to manage it themselves.
- Unless your family physician demonstrates thorough expertise and concern in bone health, have her refer you to a specialist who passes your educated muster.