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Osteoporosis - A Guide

Osteoporosis is a condition that affects the bones, causing them to become weak and fragile and more likely to break (fracture). These fractures most commonly occur in the spine, wrist and hips but can affect other bones such as the arm or pelvis.

Introduction
Symptoms of osteoporosis
Causes of osteoporosis
Diagnosing osteoporosis
Treating osteoporosis
Preventing osteoporosis
Living with osteoporosis

Introduction

Approximately 3 million people in the UK are thought to have osteoporosis, and there are over 230,000 fractures every year as a result. Although commonly associated with post-menopausal women, osteoporosis can also affect men, younger women and children.

Bone is made of a hard outer shell with a mesh of collagen (tough elastic fibres), minerals (including calcium), blood vessels and bone marrow inside. This mesh looks a bit like a honeycomb, with spaces between the different parts. Healthy bones are very dense, and the spaces inside the bones are small. In bone affected by osteoporosis, the spaces are larger, and this makes the bones weaker, less elastic and more likely to break

Bone is a living tissue that is constantly repairing itself. This process is called bone turnover. There are cells which break down old bone (osteoclasts) and cells which build new bone (osteoblasts). This process requires a range of proteins and minerals, which are absorbed from the bloodstream.

In childhood, bones grow and repair very quickly, but this process slows down as you get older. Bones stop growing in length between the ages of 16 and 18, but continue to increase in density until you are in your late 20s. From about the age of 35, you gradually lose bone density. This is a normal part of ageing, but for some people it can lead to osteoporosis and an increased risk of fractures.

Fast facts

  • Approximately 3 million people in the UK have osteoporosis.
  • There are more than 230,000 fragility fractures every year.
  • One in two women and one in five men over the age of 50 will break a bone, mainly because of poor bone health.
  • Broken wrists, hips and spinal bones are the most common fractures in people with osteoporosis.
  • Of the 70,000 people who have osteoporotic hip fractures each year, 30% will die within a year from causes related to the fracture.

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Symptoms of osteoporosis

Osteoporosis develops slowly over several years. It is likely that there will be no warning symptoms before a minor fall or sudden impact causes a bone fracture. Healthy bones should be able to withstand a fall from standing height, so a bone that breaks in these circumstances is known as a fragility fracture.

When the bones are significantly weakened (a low bone mass), breakages of the wrist, hip or spinal bones (vertebrae) are most common. A cough or a sneeze may cause the fracture of a rib or the partial collapse of one of the bones of the spine.

A fractured bone in an older person can be serious, depending on where it occurs. It may lead to long-term disability. For example, a hip fracture may lead to long-term problems with mobility.

One visible sign of osteoporosis is the characteristic stooping (bent forward) position that occurs in older people. It happens when the bones in the spine are fractured, making it difficult to support the weight of the body.

Is osteoporosis painful?

Osteoporosis usually doesn't cause pain unless a bone is broken as a result of the condition. Although not always painful, spinal fractures are the most common cause of chronic pain associated with the condition.

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Causes of osteoporosis

How does osteoporosis develop?

Bones are at their thickest and strongest in early adult life and are constantly renewed and repaired through a process called bone turnover. However, as you age, this process is no longer balanced and bone loss increases. This means that bone is very slowly broken down over time, leading to a decrease in bone density as you get older. This can cause the bone to become weaker and increase your risk of breaking a bone.

Want to know more?

Who is at risk of osteoporosis?

Osteoporosis can affect men and women. It is more common in older people, but it can affect younger people too.

Women

Women are at greater risk of developing osteoporosis than men. This is because changes in hormone levels can affect bone density. The female hormone oestrogen is essential for healthy bones. After the menopause, the level of oestrogen in the body falls, and this can lead to a rapid decrease in bone density. Women are at an even greater risk of developing osteoporosis when:

  • they have an early menopause (before the age of 45)
  • they have a hysterectomy before the age of 45, particularly when the ovaries are also removed
  • their periods are absent for a long time (more than six months) as a result of over-exercising or over-dieting

Men

For most men who develop osteoporosis, the cause is unknown. However, one particular cause of osteoporosis is linked to the male hormone testosterone, which helps to keep the bones healthy. Men continue to produce this hormone into old age, but the risk of osteoporosis is increased in individuals with low levels of testosterone.

Diseases of the hormone-producing glands

Many hormones in the body can affect the process of bone turnover. If you have a disease of the hormone-producing glands, you may be at higher risk of developing osteoporosis. Osteoporosis can be triggered by hormone-related diseases, including:

  • hyperthyroidism (overactive thyroid gland)
  • disorders of the adrenal glands, such as Cushing's syndrome
  • reduced output of sex hormones (oestrogen and testosterone)
  • disorders of the pituitary gland

Other factors

Other factors that can increase the risk of osteoporosis and broken bones include:

  • a family history of osteoporosis
  • a parental history of hip fracture
  • a low body mass index (BMI of 19kg/m2 or less)
  • long-term use of high-dose corticosteroid treatment (widely used for conditions such as arthritis and asthma), which can affect bone strength
  • heavy drinking and smoking
  • rheumatoid arthritis
  • malabsorption problems, as experienced in coeliac disease and Crohn's disease
  • some drugs used in breast cancer and prostate cancer treatment which affect hormone levels
  • long periods of inactivity, such as long-term bed rest

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Diagnosing osteoporosis

You may be diagnosed with osteoporosis because you have been identified as being at high risk and your doctor has referred you for a bone density or DXA scan.

Osteoporosis is most often diagnosed after the weakening of the bones has led to a fragility fracture. An X-ray cannot reliably measure bone density but is useful to identify fractures.

DXA scan

A bone density scan, called a dual energy X-ray absorptiometry (DXA) scan, is used to diagnose osteoporosis. It measures the density of your bones (bone mineral density or BMD) and compares this to the bone density of a healthy young adult. The difference between your measurement and that of a healthy young adult is known as a T score.

  • If your T score is between 0 and 1, you're considered to be within the normal range.
  • A T score between -1 and -2.5 is classed as osteopenia, which is the name for the category of bone density between normal and osteoporosis.
  • If your T score is below -2.5, you will be classed as having osteoporosis.

A bone density scan will diagnose osteoporosis, but having osteoporosis diagnosed or ruled out by a scan isn’t the only factor that determines your risk of fracture. Your doctor will take these factors into account before deciding whether treatment for osteoporosis is needed. The doctor will also pick the particular treatment depending on how safe and effective that drug is likely to be for you.

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Treating osteoporosis

What is good treatment for osteoporosis?

In 2001, The Department of Health (DH) published a National Service Framework (NSF) for Older People. This gives guidance to doctors, nurses and all healthcare staff on how to provide care to patients. It sets standards for the care of older people, including:

  • eliminating age discrimination
  • providing person-centred care
  • promoting older people’s health and independence
  • fitting services around people’s needs

The NSF also says that every area in England should have integrated services aimed at preventing falls and fractures.

Since then, there have been national audits on the care received by people with falls and fractures, which have shown that not everyone receives the right assessments and treatments to prevent falls or fractures. One way you can help is to ask your doctor about possible treatment if you have falls or broken bones, if you have been diagnosed with osteoporosis or if you have any of the risk factors for osteoporosis.

The DH has also created a prevention package, to support the health, wellbeing and independence of older people. The prevention package is aimed at healthcare professionals and includes information about preventing falls and effective fracture management.

The key messages for older people, family and carers are:

  • Falls are a risk as you get older, but are not inevitable. There is plenty you can do to prevent them or to reduce the harms that might result from falling.
  • Staying active and healthy (for example, with exercise and diet) is likely to keep you independent and reduce your risk of falling.
  • If you are getting unsteady or falling, seek advice from you doctor so that possible causes of falls, such as eyesight, medications, muscle strength and balance, can be identified and treated.

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Preventing osteoporosis

Your genes determine your potential height and the strength of your skeleton. However, lifestyle factors such as diet and exercise can influence how healthy your bones are. Following a healthy lifestyle throughout your life is the best way to delay the onset of osteoporosis and slow the rate at which your bones become fragile.

Regular exercise

Regular exercise is essential. Try to do a minimum of 30 minutes of exercise, at least three to four times a week. Weight-bearing exercise and resistance exercise are particularly important in improving bone density and helping prevent osteoporosis.

If you’ve been diagnosed with osteoporosis, it’s a good idea to talk to your GP or health specialist before you take up any new exercise activity, to make sure it’s right for you.

Weight-bearing exercises

Weight-bearing exercises are exercises where your feet and legs support your weight. High-impact weight-bearing exercises, such as running, skipping, dancing, aerobics and even jumping up and down on the spot, are all useful ways to strengthen your muscles, ligaments and joints. When exercising, wear footwear that provides your ankles and feet with adequate support, such as trainers or walking boots.

People over the age of 60 can also benefit from doing regular weight-bearing exercise. This can include brisk walking, keep-fit classes or a game of tennis. Swimming and cycling are not weight-bearing exercises.

Resistance exercises

Resistance exercises are exercises that use muscle strength, where the action of the tendons pulling on the bones boosts bone strength. Examples include press-ups, weight lifting or using weight equipment at a gym. If you have recently joined a gym or you have not been for a while, your gym will probably offer you an induction. This involves being shown how to use all the equipment and recommended exercise techniques. If you are unsure how to use a piece of equipment or how to do an exercise, ask a gym instructor for help.

Healthy eating

Eating a healthy, balanced diet is recommended for everyone. It can help prevent many conditions, including heart disease, diabetes and many forms of cancer, as well as osteoporosis.

Calcium is very important for maintaining strong bones. The recommended intake of calcium is at least 700mg a day. This is about equivalent to one pint of milk. Calcium can also be found in a number of different foods, including green leafy vegetables, dried fruit, tofu and yoghurt.

Vitamin D is also important for bones and teeth as it helps your body to absorb calcium. Vitamin D can be found in eggs, milk and oily fish. However, most vitamin D is made in the skin in response to sunlight. A short exposure to sunlight, without sunscreen (10 minutes twice a day) throughout the summer should provide you with enough vitamin D for the whole year.

Certain groups of people may be at risk of not getting enough vitamin D. These include people who may be housebound or particularly frail, people with a poor diet, people who keep covered up in the sunshine because they wear total sun block or adhere to a certain dress code, and women who are pregnant or breastfeeding. If you are at risk of not getting enough vitamin D through your diet or lifestyle, you can take a vitamin D supplement. For adults, 10 micrograms a day of vitamin D is recommended. The recommended amount for children is 7 micrograms for babies under six months, and 8.5 micrograms for children aged six months to three years. Talk to your GP for more information.

Other factors

Other lifestyle factors that can help prevent osteoporosis include:

  • quitting smoking: cigarette smoking is associated with an increased risk of osteoporosis
  • limiting your alcohol intake: the recommended daily limit is three to four units of alcohol for men and two to three units for women

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Living with osteoporosis

Living well

A diagnosis of osteoporosis doesn’t mean you will definitely have a fragility fracture. There are many things you can do to reduce your risk. If you’ve already had a fracture, you can still take steps to aid your recovery and reduce your risk of another fracture.

Self care

Self care is an essential part of daily life. It means that you take responsibility for your own health and wellbeing, with support from the people involved in your care. Self care includes the things you do each day to stay fit, maintain good physical and mental health, prevent illness or accidents, and effectively deal with minor ailments and long-term conditions. People living with long-term conditions can benefit enormously if they receive support for self care. They can live longer, have less pain, anxiety, depression and fatigue, have a better quality of life and be more active and independent.

Preventing falls

You can change aspects of your home environment to reduce the risk of fracturing or breaking a bone. It is a good idea to check your whole house for hazards that you may trip over, such as trailing wires. Make sure rugs and carpets are secure, and keep rubber mats by the sink and in the bath, to prevent slipping.

Have regular sight and hearing tests. Some older people may need to wear special protectors over their hips to cushion a fall. Your GP can offer you help and advice about changes to your lifestyle. NICE has also produced guidance about the assessment and prevention of falls in older people.

Healthy eating and exercise

Regular exercise and a healthy diet are recommended for everyone, not just people with osteoporosis. They can help prevent many conditions, including heart disease and many forms of cancer. Try to eat a balanced diet, containing all the food groups, to give your body the nutrition it needs. Exercising regularly can increase the strength of the bones, relieve stress and reduce fatigue.

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