Definition

Osteoporosis (“porous bone”) is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and making it susceptible to fractures, particularly at the hip, spine, and wrist, although other skeletal sites may also be affected.

Put simply, osteoporosis is a condition in which bones become weak and may break after a simple fall, while in advanced cases even a sneeze or bumping into a piece of furniture may result in a fracture.

Prevention

Approximately 85–90% of adult bone mass is acquired by the age of 18 in girls and by the age of 20 in boys. Building strong bones during childhood and adolescence can help prevent osteoporosis later in life.

The following five steps, when combined, can improve bone health and help significantly in preventing osteoporosis:

• Include calcium and vitamin D in your daily diet
• Exercise daily and strengthen your muscles
• Do not smoke and do not consume excessive alcohol
• Discuss with your doctor your risk of developing osteoporosis and ask when you should have a bone density test
• Have your bone density measured at the appropriate time

Studies on the management of osteoporosis in rural populations have shown that prevention programmes significantly reduced the rate of hip fractures while also saving substantial healthcare costs.

Incidence and Prevalence of the Disease

Osteoporosis is mainly considered a disease of older people, but it may also affect younger individuals.

A. Sex: 80% of people with osteoporosis are women and 20% are men. It is clear that women are more vulnerable to the disease.

B. Ethnicity: There are differences in the risk of developing osteoporosis depending on ethnic background. Demographic data from international studies indicate the following for people over 50 years of age:

Hispanic populations:

• Men: 3% osteoporosis and 23% osteopenia
• Women: 10% osteoporosis and 49% osteopenia

Caucasian and Asian populations:

• Men: 7% osteoporosis and 35% osteopenia
• Women: 20% osteoporosis and 52% osteopenia

African populations:

• Men: 4% osteoporosis and 19% osteopenia
• Women: 5% osteoporosis and 35% osteopenia

It is generally acknowledged that osteoporosis is underdiagnosed and that the necessary pharmacological treatment is often not followed, both in Caucasian women and in women of African descent.

Comparatively, the most rapid increase in the risk of developing the disease is observed in Hispanic populations. In fact, it has been estimated that in the United States the cost of osteoporotic fractures in these populations will rise dramatically from 754 million dollars in 2005 to 2 trillion dollars in 2025.

Cost

In 2005, fractures related to osteoporosis had an annual cost of 19 million dollars in the United States of America.

In 2025, expert analysts estimate that the annual cost will rise to 25.3 million dollars.

Symptoms

Naturally, you cannot feel your bones becoming weaker. You may already have osteoporosis or be at risk of developing the disease. Unfortunately, very often, a fracture is the first sign of osteoporosis. A simple fall, a sneeze, or even a sudden movement may lead to a fracture.

Vertebral fractures may initially present as persistent pain in the back or lower back, loss of height, or body deformity with forward curvature of the thorax (kyphosis) or sideways deviation (scoliosis).

Women may lose up to 20% of their bone density during the first 5 to 7 years after menopause, making them much more vulnerable to developing the disease.

Risk Factors

Some people are more likely to develop osteoporosis than others. Certain factors increase this likelihood and are called risk factors. These include:

• Female sex
• Older age
• Family history of osteoporosis or fracture
• Thin and small body frame
• History of fracture
• Low levels of sex hormones

In women:

• Low estrogen levels (including menopause)
• Amenorrhea (absence of menstruation)

In men:

• Low testosterone and estrogen levels

Dietary habits:

• Low calcium intake
• Low vitamin D intake
• Excessive intake of protein, sodium, and caffeine

Other risk factors include:

• Sedentary lifestyle (lack of physical activity)
• Smoking
• Excessive alcohol consumption
• Certain medications (e.g. corticosteroids, contraceptives)
• Certain diseases, such as rheumatoid arthritis, anorexia nervosa, gastrointestinal disorders, and others

Fractures

Approximately 1 in 2 women over the age of 50 and 1 in 4 men of the same age will experience a fracture related to osteoporosis at some point during the rest of their lives.

Fractures related to osteoporosis can occur in any bone, but they are much more likely to occur at the hip, vertebrae, and wrist.

In the United States, osteoporosis was estimated to be responsible for 2 million fractures in 2005, distributed as follows:

• 297,000 at the hip
• 547,000 in the vertebrae
• 397,000 in the wrist bones
• 135,000 in the pelvis
• 675,000 at other skeletal sites

The number of osteoporotic fractures was expected to reach 3 million annually by 2025 in the United States.

Women who have sustained one hip fracture are four times more likely to sustain a second fracture.

Osteoporotic fractures reduce people’s quality of life.

The rate of osteoporotic fractures is 2 to 3 times higher in women than in men. Nevertheless, the annual mortality following hip fracture in men is twice as high as in women.

A woman’s likelihood of sustaining a hip fracture is equal to the combined likelihood of developing breast, ovarian, and uterine cancer.

In 2005, approximately 293,000 individuals were hospitalized because of fracture of the femoral neck, a common type of hip fracture. Osteoporosis was shown to be the main cause in most cases.

Twenty-four percent of patients over the age of 50 with a hip fracture die within the first year after the fracture.

One in five ambulatory patients who sustain a hip fracture will require long-term nursing care.

Six months after a hip fracture, only 15% of patients are able to walk without assistance.

In addition to hip fractures, vertebral fractures are also associated with increased mortality.

Caucasian women over the age of 65 have twice the incidence of fractures compared with women of African descent.

Many people sustain fractures after a fall. In 2005 in the United States, 15,802 people over the age of 65 died from injuries due to falls.

Diagnosis

Special tests known as bone density measurements can assess bone density at various sites in the body. Experts recommend DXA (dual-energy X-ray absorptiometry) at central skeletal sites as the best method.

This special test can:

• Show whether the patient has low bone mass before sustaining a fracture
• Determine whether the patient is losing bone mass or remaining stable, by repeating the test at intervals of one year or more
• Predict the likelihood of future fracture
• Help the physician decide whether pharmacological treatment is needed

It should also be noted that:

• The test is recommended every two years
• The increased use of bone density testing, and the resulting initiation of treatment for osteoporosis, has led to a significant reduction in hip fractures
• Bone density measurement is an important determinant of fracture risk even in hospitalized patients
• There has been an approximately fivefold increase in medical visits related to osteoporosis over the last 10 years
• Detecting low bone density in an individual with no symptoms of osteoporosis is just as important for fracture prevention as high blood pressure and high cholesterol are in preventing myocardial infarction or stroke

Some medical devices used for bone density measurement are able to apply a tool/algorithm that calculates a specific patient’s probability of sustaining a hip fracture over the next 10 years. This tool is called the FRAX score and takes into account many of the factors mentioned above.

The FRAX score is especially important in individuals with osteopenia, where it may be difficult to decide whether pharmacological treatment should be initiated.