Focus on Osteoporosis
By Suresh Velagapudi, M.D.
 Bones are the structural foundation and scaffold upon which the rest of the body is built. Bone mass is a measure of both the size and weight of all the bones in our bodies. The health and the strength of bones are affected by genetics, diet and exercise, general health status, medications, environmental influences and a variety of other factors. Not surprisingly, bone mass increases rapidly from birth, through childhood and into adolescence. Bone mass reaches a peak and our bones are as big and as strong as they are going to be by the time we are in our twenties. An individual's bone mass then usually remains quite stable up until the age of thirty-five to forty-five at which point it usually begins to gradually decrease with further age. If the quality of bone diminishes sufficiently, osteoporosis is the result.
In 2001 the National Institutes of Health defined osteoporosis as "a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture." While it is common knowledge that the elderly are at risk for developing osteoporosis, a number of other risk factors have also been identified. Increased risk is noted to exist in postmenopausal Caucasian women as well as in smokers and those who consume more than two alcoholic drinks per day. First-degree relatives of individuals who have had an osteoporosis fracture are also at increased risk, as are those who must take steroid medications for over three months. Among other factors, reduced levels of activity also predispose to fragility fractures. The number of fractures due to osteoporosis occurring annually in the United States alone is approximately 1.5 million and is increasing annually. The most common osteoporotic (fragility) fractures occur in the wrist, the spine and the hip. Annually in the United States we spend approximately 20 billion dollars treating patients solely for osteoporotic fractures.
Clearly, the most effective way to decrease the risk of fragility fractures is prevention. There are a number of activities and precautions that individuals can take to reduce their risk. Maintaining levels of weight-bearing activities (walking) and doing light upper body weight training exercises are very helpful activities. Exercises to improve balance may be useful, and, if they are not effective, appropriate use of ambulatory aids (canes, or walkers, for instance) can reduce the risk of falls. Attending the proper eye care can reduce vision loss, and the removal of throw rugs and area rugs from the home can also decrease the risk of tripping and falling. Proper diet, too, can help keep bones healthy. Calcium and Vitamin D are particularly essential to goon bone health. On average, calcium intake should be 1200 milligrams per day and Vitamin D should be 400 International Units (UI's) per day (increasing to 600 UI's daily at age 50) from dietary intake and/or nutritional supplements. But even when one does all the right things, osteoporosis and the associated increased risk of fractures can occur. In that case early diagnosis is critical so that effective treatment can be initiated before the process becomes too advanced.
 Measurement of bone mineral density (BMD) is the standard method of assessing the health and subsequent strength of bones. Over the years different types of technology have been used to measure bone density but today there is one "gold standard" - Dual Energy X-ray Absortiometry (DEXA) - that is the most accurate and reproducible means yet developed. A DEXA scan measures bone density at the hips and lower spine, two of the sites commonly involved with fragility fractures. The measured BMD is then compared to the normal peak values for young adults and is reported as a "T-score" which is the number of standard deviations that an individual BMB varies from normal and is the standardized method of measurement developed by the World Health Organization. A negative T-score indicates a bone density lower than that found in young, healthy individuals but a T-score between 1 and -1 is considered normal. Fracture risk doubles for every standard deviation below normal. A T-score between -1 and -2.5 is one to two and a half standard deviations below normal and is considered osteopenia, indicating that one is on the way to developing osteoporosis and is already 2 to 5 times more likely than a healthy young adult to develop a fragility fracture. A T-score of -2.5 or worse indicates that the individual has osteoporosis and is more than five times at risk. Anyone with a T-score of less than -2.5 who has also had a fragility fracture is considered to have severe osteoporosis.
DEXA scanning is now recommended for all women over 65 years of age, younger postmenopausal women with any additional risk factors, any postmenopausal women with a fracture and any other individuals at risk (steroid dependent persons, for instance). Effective treatment that can prevent or actually reverse osteoporosis is now available and DEXA scanning every one to two years is used to accurately monitor the effectiveness of treatment. Thankfully, appropriate preventive measures, early diagnosis, effective treatment and accurate monitoring should greatly reduce the risk of osteoporosis fractures in the future.
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