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Thinning Bones: Osteoporosis
By Dr. Shafiq Qaadri, MD

Our bones are the scaffolding upon which muscles contract and relax, allowing for fluid movement and proper posture. They are not static but alive, strengthening with exercise or weakening because of disuse and lack of calcium and poor nutrition.

But an osteoporotic skeleton is like imitation bone, a calcium veneer with hollowing insides and unrepaired holes -- like termites in the woodwork. Indeed, the microscopic details of osteoporotic bone resemble a construction site report: There is a "loss of mechanical support and strength, microarchitectural deterioration, more bone pits and poor remodelling."

It sounds like an engineering survey for a contractor who used shoddy materials, but you are the contractor.

Osteoporosis (literally, porous bones) can affect any of the body's 206 bones, but the hip, spine and wrist are especially vulnerable. The suffering is immense. "I didn't know I had osteoporosis till I broke my hip," says a 64-year-old woman who had slipped from her bed. "I've lost my independence. . . . I may have to go into a [nursing] home."

Consider the number of people afflicted: Today, 1.4 million Canadians have osteoporosis, and three million more are at risk of developing the condition. Each year, 18,000 people fracture their osteoporotic hips, resulting in prolonged care and disability for thousands, and claiming 4,000 lives.

"Osteoporosis is an important problem, and it's increasing . . . [as] the Baby Boom generation ages," says Dr. Jay Silverberg, an associate professor of medicine at the University of Toronto.

But it's not just a disease of aging. Doctors are beginning to see young people with osteoporosis.

Seven years ago, Salima Ladak-Kachra, now 32, crushed four bones in her spine after slipping onto a ceramic floor. "I couldn't walk for six weeks, and I still have back pain. . . . It's changed my whole life around."

Ms. Ladak-Kachra had several risk factors for osteoporosis. Weighing only 87 pounds, she admits she was too body-conscious. "I wanted to be like the girls in the magazines." Consequently, she avoided milk, had 10 caffeines a day and minimal exercise. Both of her parents have osteoporosis, so she was also genetically predisposed to develop the condition early.

The most common bone condition in North America, osteoporosis affects one out of four women, and one in eight men, according to Gwen Ellert, RN, and Dr. John Wade, authors of The Osteoporosis Book: Prevention and Treatment for Men and Women.

Patients are often fearful once they have been diagnosed with osteoporosis, having to live with a chronic weakness, worrying that any strain or bump may lead to broken bones. "I'm nervous about falling," says retired teacher Pauline Helferty, 59, who recently tripped while on vacation but did not fracture any bones. "I thought, that's it. My bones are brittle . . . I must have cracked something."

Canadians need to learn more about the prevention, consequences and management of the disorder described by the Osteoporosis Society of Canada as "one of the most common, yet least understood diseases."

Why is osteoporosis increasing so rapidly?

Many factors conspire: modern lifestyle, family history, the Canadian winter, hesitant doctors and cost constraints.

Bones are strongest by age 30, so nutrition in earlier years is critical for bone health. Yet the modern lifestyle seems toxic for healthy bones. "The diets of body-conscious teens often lack calcium-rich milk and milk products," Karine Bohme and Dr. Frances Budden say in their book The Silent Thief: Bone-Building Exercises and Essential Strategies to Prevent and Treat Osteoporosis.

Caffeine, alcohol and smoking -- three staples of modern life -- reduce the amount of calcium absorbed into the blood. And with young adults getting more screen-time in front of computers or TV, giving their bones minimal workouts, bone strength is not maximized.

Vitamin D is made in skin exposed to direct sunlight, and helps the body absorb calcium into blood and construct sturdy bone tissue. But the decreased ray-time of long Canadian winters predisposes the entire population to developing osteoporosis. And older people are especially affected, as their skin makes less vitamin D when activated by sunlight.

When asked if other family members have osteoporosis, many patients reply: "Everybody."
Just as your height, build and facial features are inherited, the chance you will develop osteoporosis starts in your genes. "There is clear evidence of genetic modulation of bone," says Dr. John Eisman, a researcher at the Garvan Medical Institute in Sydney, Australia. Dozens of genes are involved, which not only predict your risk of osteoporosis but even which joint you're likely to fracture -- hip, spine or wrist.
Doctors share the blame for the increase in osteoporosis, and must identify patients earlier and manage them more aggressively.

It has been estimated that four out of five patients who have had their first osteoporotic fracture -- known as fragility fractures, a clear sign of weak bones -- do not receive adequate treatment to prevent further fractures. "Many end up with a fracture, then another fracture . . . but never seem to get diagnosed or treated for osteoporosis," says Dr. Rowena Ridout, an assistant professor of medicine at the University of Toronto.

It seems that too many doctors and patients accept the idea of the classic little old lady, with bones frozen, hunched over permanently with a cane, walking slowly with wide baby-steps. But this scenario is entirely preventable, and "not just a natural part of aging," says Dr. Heather McDonald-Blumer, clinical director of the Multidisciplinary Osteoporosis Program at the University of Toronto.
Marianne Williams, for example, was diagnosed with osteoporosis four years ago at the age of 48. "My doctor just didn't take it seriously enough . . . it was scary because it implies old age." Her next bone tests revealed that her bones were considerably weaker. She was appalled when her physician said: "This isunusual. . . . Maybe you won't be able to walk in five years."

Strangely, doctors don't seem to realize that men have bones too, and do not test or treat them for osteoporosis. Yet men do suffer from bone thinning: 30 per cent of all hip fractures occur in men, and they tend to have a longer recovery, more complications and a higher death rate.
"Osteoporosis, not just for women any more" is the title of an article recently published in The Canadian Journal of Continuing Medical Education. Indeed, Dr. McDonald-Blumer estimates that 10 per cent of the patients attending her clinical program are men.

Ideally, everybody's bone density would be measured with special X-rays annually after the age of 55. This would establish a baseline report -- the initial engineering survey -- similar to screening for breast cancer with mammograms, or for prostate cancer with annual blood tests.
Patients with thinning bones could be identified much earlier than current practice, and their response to therapy -- how quickly their bones got stronger -- could be followed. But screening is expensive, and the health-care system does not reward preventive care.

Preventing and treating osteoporosis is complex.

Adequate dietary calcium is fundamental. But many Canadians don't get the quantity recommended by the Osteoporosis Society of Canada. For example, for people over 50, the recommended calcium requirement is now 1,500 milligrams a day -- the equivalent of five eight-ounce glasses of milk.
Yet research reveals that half of all postmenopausal women -- the group that needs it most -- get less than 500 mg of daily calcium.

Physicians: As specialists, they help family physicians manage challenging cases by assessing patients, cross-checking treatment(s), upgrading therapy or performing research-level testing.

Physiotherapists: Patients with osteoporosis are confused about which exercises, machines, weights and equipment are good for bones. Like personal trainers, physiotherapists tailor training programs for each patient's needs and capacities, choosing exercises that are safe and effective.

Dietitians: They help patients make food-choices that are bone-smart. They do a caffeine-reality check, suggesting alternative, healthy foods such as calcium- and vitamin D-fortified milks, powders and juices.

Nurse-practitioners: They are disease-educators who reinforce the doctor's message, help patients make informed decisions, and explain the nuances of treatments. They also help to screen, enroll, and monitor patients in clinical research trials, helping to test new therapies.

Pharmacists: They dispense medications, making sure each patient receives the most appropriate choice of drugs. Most physicians have been saved by alert pharmacists, who make sure drugs are prescribed intelligently, in the right dosage, before the expiry date, helping to avoid drug interactions, allergies and side effects.

Occupational therapists: They give practical advice about preventing falls, managing dizziness, safe lifting and bending, non-slip mats, custom shoewear, grab bars for the bath, hip protectors and coping with pain.

With the risks associated with estrogen, hormone-replacement therapy is no longer a first choice for the prevention and treatment of osteoporosis. There are, however, non-hormonal options: Fosamax and Actonel are powerful and much-needed medications for bone strengthening, the only class of drugs given to both women and men.

These medications block the bone-dissolving cells, allowing the bone-building to continue. Patients treated with these agents show substantial strengthening in bone density X-rays, reducing fracture rates by about 60 per cent.

The classic little old lady -- or man -- should not be part of anyone's future. Canadians need to start actively caring for their bones, with appropriate diet, exercise, supplements, tests and, if needed, medications. As one Toronto-area gynecologist said: "We all deserve to stand tall."

Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education lecturer. www.doctorQ.ca

An osteoporosis primer

Are you at risk?

Age 50 or older
Female, especially postmenopausal
Male with low testosterone (andropause)
Menopause earlier than age 45
Insufficient dietary calcium
Insufficient sunlight exposure (less vitamin D)
Lack of exercise
Caucasian or Asian background
Small-boned, thin (less than 57 kilogram bodyweight)
Excess smoking, caffeine, alcohol
Thyroid problems
Family history of osteoporosis

For those over 50:
Adequate dietary calcium (1,500 milligrams a day)
Adequate vitamin D (800 international units a day)
Calcium supplements such as Tums, Caltrate, fortified milk and juices
Weight-bearing exercise: walking (four hours a week), jogging, dancing, aerobics
Resistance exercises: lifting free weights, weight-training machines, racquet sports, impact sports
Proper lifting techniques
Fall prevention
Annual medical checkups
Testing bone density

-- Adapted from the Osteoporosis Society of Canada, and the National Osteoporosis Foundation (USA)

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