Living with
Osteoporosis

What is osteoporosis?

Osteoporosis is a condition where bones become weakened, fragile and more likely to break. The word itself, literally means ‘porous bones,’ and decreased bone density is the key feature of the disease.

Osteoporosis can affect anyone but is significantly more common in post-menopausal women. A healthy, well-balanced diet and weight-bearing exercise can help prevent bone loss. You can also take medication to strengthen already weak bones; however, this requires early diagnosis which is often difficult.

How do you know you have osteoporosis?

A person with osteoporosis may experience no symptoms or warning signs until they break a bone. Typically fractures due to bone changes associated with osteoporosis occur in the spine, wrists, hip, pelvis, upper arms or hands.
However, you can also experience the following due to weakened bones caused by osteoporosis:

• Back pain caused by fracture or collapse of the vertebrae (bones of the spine).
• Loss of height gradually over time and a stooped posture caused by curvature of the spine from fractures of the vertebrae.
• A bone that breaks suddenly or unexpectedly. As stated, you may not know you have osteoporosis until it is too late, and you have fractured a bone. In this way, osteoporosis is known as the “silent crippler”.

What is osteopenia?

Osteopenia is the stage before osteoporosis, when you have a lower than normal bone density for your age, but low enough not to be classified as having osteoporosis.
Being diagnosed with osteopenia means you are at higher risk of developing osteoporosis and need to take serious steps to avoid further bone loss.

What causes osteoporosis?

Osteoporosis is more common in women. According to the National Osteoporosis Foundation of South Africa (NOFSA), the risk of a woman experiencing a fracture related to bone changes associated with osteoporosis in her lifetime is 30-40 %. However, while most people think that men do not get osteoporosis, new evidence suggests that, in fact, one in five men are affected by the condition – much higher than originally thought.

Bone, as a living tissue, is constantly in a state of renewal, with old bone being broken down and replaced by new bone. Osteoporosis occurs when the breakdown of bone exceeds the rate of replacement.
Another common misconception about osteoporosis is that it is an “old woman’s disease;” while studies show that after your early 20s, bone replacement slows, with most people reaching their peak in bone mass by the age of 30 or 35 years. Bone loss can even start in women as young as 25 years old and sometimes in even younger people, or rarely in children.

How likely you are to develop osteoporosis depends partly on how much bone mass you attained while growing during childhood and adolescence.
Other factors that can increase the likelihood that you will develop osteoporosis can include:

• Sex: Women are much more likely to develop osteoporosis than men are – this is particularly so for women post-menopause.
• Age: The risk of osteoporosis increases with age as bone mass is lost, especially after 65 years of age.
• Genetics/Family history: You have a greater chance of developing osteoporosis if a close family member has the condition – particularly if one of your parents has ever fractured a hip.
• Low BMI: People with a small body frame or a low BMI are at greater risk of developing osteoporosis (‘BMI’ stands for Body Mass Index, and is the relation of you weight in kilograms to your height in meters). This can be true for people who have low body weight from anorexia nervosa or bulimia, for example.
• Low levels of gonadal hormones: Low levels of gonadal hormones, or sex hormones, in the body tend to cause weakened bones. The reduction of oestrogen levels in women post-menopause is one of the greatest risk factors for developing osteoporosis.
  Men have a more gradual reduction in testosterone levels as they age; but, treatments for prostate cancer can significantly reduce testosterone levels in men and accelerate bone loss, potentially causing osteoporosis.
• Thyroid problems: An over-active thyroid, known medically as hyperthyroidism, produces excesses thyroid hormone which stimulates the breakdown of your bones.
• A low calcium intake: A lifelong lack of calcium, hypocalcaemia, can play a role in the development of osteoporosis, as calcium is the key mineral needed for bone production and growth. Lowered levels of calcium in your body can result in weak and porous bones being formed. This can occur if you suffer from malnutrition.
  Additionally, recent gastrointestinal surgery can also reduce the size of your stomach or intestine, limiting the amount of surface area available to absorb nutrients, including calcium.
• Long-term use of corticosteroids: Using corticosteroid medications, like cortisone, especially at high doses for periods of three months or more, can interfere with bone replacement.
• Certain medical conditions: You have a much higher risk of developing osteoporosis if you have certain chronic diseases or inflammatory or malabsorption conditions like coeliac disease, inflammatory bowel disease (IBS), kidney or liver disease, cancer, systemic lupus erythematous or rheumatoid arthritis, among others.
• Sedentary lifestyle: If you are physically inactive and do not do any weight-bearing activity, there is a greater chance that you will not develop or maintain a significant bone mass. You will therefore have increased risk of developing osteoporosis.
• Excessive alcohol consumption: Regular consumption of more than two alcoholic drinks per day can speed up bone loss. It can also reduce your body’s ability to absorb calcium, especially if you drink alcohol while partaking in a meal.
• Smoking: While the exact role of tobacco smoke in the development of osteoporosis is yet unclear, evidence shows that exposure to tobacco contributes to the development of weaker bones.

How do you prevent osteoporosis?

You must try to keep your bones strong and healthy, especially if you know you are at risk of developing osteoporosis. This may include:

• Being physically active: Not only does exercise increase bone and muscle strength, it also improves balance, flexibility and co-ordination. According to NOFSA, walking and appropriate weight-lifting are the best forms of exercise you can do to build and maintain bone density. Both of these forms of exercise make your bones work against gravity, providing a weight to bear and grow against.
  Please see our weight-bearing exercise programme here.
• Eating well for good bone health: It is important to eat a healthy, well-balanced diet that is rich in a range of different nutrients, including proteins, high-fibre and low-GI carbohydrates and healthy, unsaturated fats, in addition to low-fat dairy products and vitamins and minerals that are found in high amounts in fruit and vegetables.
  Be sure to include lots of foods rich in calcium in your diet. Calcium is a mineral found in dairy products, dark green leafy vegetables like spinach and broccoli, the bones of canned oily fish and in soy products like tofu. Calcium is essential for the development of strong, healthy bones and the prevention of osteoporosis and other bone diseases like arthritis. Men and women between the ages of 18-50 years need 1 000 milligrams of calcium per day, while women older than 50 years and men older than 70 years need 1 200 milligrams per day.
  See Cooking from the Heart for healthy recipes and to find out more about how to incorporate more foods that are high in calcium into your diet.
• Quitting smoking: Talk to your doctor about ways to quit smoking, as smoking increase your risk of developing osteoporosis.
• Limiting your alcohol consumption: Do not drink more than two alcoholic beverages per day, as any more than this intake can speed up bone loss and reduces your body’s ability to absorb calcium, especially if you drink alcohol during a meal.
• Cutting down on caffeine: Caffeine may increase calcium loss in the urine. However, moderate caffeine use (about two cups of coffee a day) is probably not harmful if your diet contains enough calcium.
• Getting plenty of vitamin D: Vitamin D improves your body’s ability to absorb calcium. In South Africa, it is quite possible to get enough vitamin D from your exposure to sunlight; however, good dietary sources of vitamin D include eggs, fish (such as salmon and canned tuna, for example) and liver.
  NOFSA reports that there is emerging evidence that suggests the minimum blood level of 25-hydroxy vitamin D that is optimal for fracture prevention is 70-80 nmol/l. This level would require a daily vitamin D intake of at least 800-1000 IU (20-25 µg/day), which is approximately double the intake recommended in most countries. This may suggest that recommendations for vitamin D supplementation, especially for older adults, is underestimated in many cases.

How is osteoporosis diagnosed?

Prevention of osteoporotic fractures requires early diagnosis by your doctor. Your doctor will take a full medical history, physical examination and/or additional blood tests to determine whether you are at risk for osteoporosis and bone fractures.

To confirm that you have osteoporosis though, your doctor must measure your bone density. A bone density test (bone densitometry) uses radiography (X-rays) to measure how many grams of calcium and other minerals are inside of your bones per square centimetre. This measurement is called your bone mineral density or BMD.

What do bone densitometry measurements mean?

The World Health Organization has defined threshold measurements for osteoporosis, derived from bone density measurements in a population of healthy young adults.
Osteoporosis is diagnosed when a person’s BMD is more than 2.5 standard deviations below this reference measurement, while osteopenia is diagnosed when the measurement is between 1-2.5 standard deviations below the reference measurement.

Living and managing

After you are diagnosed with osteoporosis it is still important that you keep your bones strong and healthy as per the suggestions under prevention of osteoporosis.
Additionally, you may want to take steps to reduce the risks of suffering a fall inside your home. To read more about how to make your home ‘fall-free’, you can refer here.

What is the treatment for osteoporosis?

Your doctor may base your treatment on an estimate of your risk of breaking a bone in the next 10 years and your BMD measurement on bone densitometry. If your risk is not high, treatment might not include medication and might instead focus on modifying risk factors for bone loss (for example, maintaining a healthy diet) and reducing your chance of suffering a fall (namely, modifying your house or living space to reduce hazards).

However, based on your BMD and what your underlying factors for developing osteoporosis are, you doctor may prescribe one of the following medications:

• Bisphosphonates: This medication can be used for both men and women at increased risk of fracture and is the most commonly prescribed osteoporosis medication. Examples include alendronate, risedronate, ibandronate and zoledronic acid.
  Common side-effects that bisphosphonates cause include nausea, abdominal pain and heartburn-like symptoms, but you are less likely to experience these side-effects if you take your medication properly.
  Additionally, this form of medication can also be taken intravenously or by injection; however, while these methods may be easier to remember than taking a weekly or monthly oral tablet (injection may only be needed quarterly or yearly, for example), they are usually more expensive.
• Monoclonal antibodies: Compared to bisphosphonates, the monoclonal antibody, denosumab, produces similar or better bone density results, while reducing the chance of all types of fractures. Denosumab is typically delivered via a subdermal injection every six months. If you take denosumab, you might have to continue doing so for the rest of your life.
  Very rare complications of bisphosphonates and denosumab, include fractures in the middle of the thighbone or delayed healing of the jawbone (known as ‘osteonecrosis of the jaw’), which can occur after invasive dental procedures such as pulling a tooth. Therefore, you should have a dental examination done before starting these medications and should continue to take good care of your teeth and see your dentist regularly.

• Hormone-related therapies: Oestrogen, in the form of hormone-replacement therapy (HRT), can help maintain bone density after a woman undergoes menopause. However, oestrogen therapy can increase the risk of blood clots and some form of caners, such as endometrial and breast cancers.
  Raloxifene is a medication that replicates the effects of oestrogen on bone density in postmenopausal women, without some of the risks associated with oestrogen.
  In men, on the other hand, osteoporosis might be linked with the gradual decline in age-related testosterone levels; but while testosterone-replacement therapy is available, it is not recommended for osteoporosis treatment.
• Bone-building medications: Your doctor may suggest medications that stimulate bone growth if other treatment options have failed to show desired results. However, these treatments can only be used for limited periods of time. This type of medication includes teriparatide, abaloparatide and romosozumab.

What are the complications of osteoporosis?

You may experience bone fractures, particularly in the spine or hip, as a complication of osteoporosis. Fractures can be caused by a fall and can result in back pain, chronic persistent pain, disability or even death.