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Bone Health & Osteoporosis Center Treats "Silent" Disease - 09/04/2007

Your skeleton is your scaffolding. Yet it’s easy to take your bones for granted. You can’t see them, and, unlike many muscle and joint problems, some of the most common — and most serious — bone conditions produce no symptoms. Until it’s too late.

“One of the biggest dangers of osteoporosis is that it doesn’t cause any pain or symptoms until the bone breaks, which can be very painful,”says Latha Dulipsingh, M.D., FACP, FACE, medical director of The Hospital of Central Connecticut’s Bone Health & Osteoporosis Center. “It’s called a ‘silent disease.’” The Bone Health Center provides diagnosis, treatment and monitoring of a number of conditions affecting the bones, including hyperthyroidism, vitamin D deficiency and Paget’s disease, in which newly formed bone is architecturally unstable. But osteoporosis is by far the most common metabolic bone problem, Dulipsingh says. The National Osteoporosis Foundation estimates that 10 million Americans have osteoporosis, and an additional 34 million have low bone mass (osteopenia), putting them at increased risk for osteoporosis. That’s one in two people over age 50 (although osteoporosis can strike at any age).

Osteoporosis causes bones to become weak, brittle and at risk for breaks — usually in the hip, spine and wrist. Though women are four times more likely to get osteoporosis, men also get it. Many people probably aren’t aware they have, or are at risk for, the disease. When Joan Mercier and her husband go to a friend’s for dinner, she always knows where to sit at the table — the place with the big glass of milk. “I’ve always been a milk drinker, says Mercier, 72, of New Britain. “I drink milk so much it never occurred to me I could have a problem with bone health.” But 10 years ago Mercier’s primary care physician ordered a bone density test as a precaution. It showed osteoporosis. “I was so surprised,” she says. “I would never have suspected it.”

Breaking down, building up
The term osteoporosis means “porous bone,” and refers to an actual thinning of bone tissue. Though hard and generally strong, bone is living tissue that is constantly being broken down and re-formed through a process called remodeling. The goal of remodeling is to maintain maximum bone density and repair breaks or other damage. The two-part remodeling process includes resorption, when old bone tissue is broken down and removed by osteoclast cells; and formation, when osteoblast cells form new bone tissue. In children and teen-agers, new bone is added faster than old bone is removed, so bones grow and become denser. In the 20s and 30s, more old bone tissue is removed than replaced, so bones become less dense. Osteoporosis occurs when bone removal happens too quickly, replacement too slowly or both. Age is the main reason for this imbalance, Dulipsingh says. Remodeling is controlled by hormones that decline with age, including estrogen (in women) and testosterone (in men).Women can lose up to 20 percent of their bone mass in the five to seven years following menopause. Other substances that regulate
remodeling include calcitonin, vitamin D and parathyroid hormone. Mercier’s physician ordered her initial bone density scan because of parathyroid surgery she’d had years
before. Located behind the thyroid gland in the neck, the parathyroids produce a hormone that regulates calcium throughout the body, including how much is stored in the bones.

Mind your T’s and Z’s
If you’ve broken a bone, you know how painful it can be. The hip and spine fractures that are common with untreated osteoporosis can cause severe pain, long-term disability — even death. One in two women and one in four men over 50 will have an osteoporosis-related fracture in her/his remaining lifetime, according to the National Osteoporosis Foundation. “This is a very prevalent disease that can have drastic outcomes if not treated,” Dulipsingh says. “Awareness is extremely important.” Fortunately, awareness is on the rise, so most people discover osteopenia and osteoporosis through screenings vs. bone breaks, she says. Screening is recommended for men and women over 65, postmenopausal women under 65 and anyone with risk factors (see sidebar).

X-ray can’t detect low bone density until 40 percent of bone mass is lost, so doctors use other tests, including blood and urine tests and scans of various areas of the body. The hospital has a portable machine that measures bone density in the heel and can be useful for preliminary screening. The Hospital of Central Connecticut also offers two types of painless bone mineral density (BMD) scanning: Dual Energy X-ray Absorptiometry (DXA or DEXA) and Quantitative Computed Tomography (QCT). BMD tests yield a “T-score” comparing your bone density with that of healthy young women or men and
a “Z-score” comparing your density with that of others your age, gender, and race.
A T score from -1 to -2.5 indicates the beginning of bone loss (osteopenia); a score below -2.5, osteoporosis.

Keep your bones strong
You can’t control your hormone levels without medication, but you can minimize or eliminate other osteoporosis risk factors, including smoking, insufficient calcium, lack of weight-bearing exercise and other factors (see below). In addition to declining testosterone, alcoholism and steroid use are common causes of osteoporosis among men, Dulipsingh says. “All of us should be on preventive measures,” she says.
Even with lifestyle changes, some people need medication to prevent or slow osteoporosis. Most osteoporosis drugs slow resorption, the breakdown of old bone.

They include:
• Bio-phosphonates such as alendronate (Fosamax), ibandronate (Boniva), and risedronate (Actonel).
• Hormone therapy, including estrogen without progestin (estrogen replacement therapy) or estrogen and progestin (hormone replacement therapy) for some women. Testosterone can help pre-vent osteoporosis in men but hasn’t been approved for its treatment.
• Selective estrogen receptor modulators (SERMs) such as Raloxifene.
• Calcitonin (Calcimar or Miacalcin), a naturally occurring hormone that helps regulate calcium levels in the body.

Bone-building medications include teriparatide (Forteo), a parathyroid hormone used to treatmen and postmenopausal women with severe osteoporosis. “It’s important to remember that even with medication you’ll still need to take calcium and vitamin D supplements, perform weight-bearing exercise regularly and eat a healthy diet,” says James Bernene, M.D., a board-certified endocrinologist and chief of the Department of Medicine at The Hospital of Central Connecticut. “For some patients, the combination of medication and lifestyle changes can reverse bone loss, up to a point.”

Joan Mercier has been taking Fosamax for 10 years and saw initial improvement in her bone density. She’s convinced the medication saved her from serious injury after a fall two years ago. “I thought for sure I’d end up in the hospital with a broken hip,” she recalls. “Once I got up and saw I was OK, I said to my husband, ‘I guess that Fosamax is working!’” Unfortunately, even with medication and lifestyle changes, patients can continue to lose bone mass. A scan two months ago showed that Mercier’s density is down again, so her doctor referred her to the Bone Health & Osteoporosis Center. Dulipsingh works with patients’ primary care physicians to find the safest and most effective medications and provides monitoring and follow-up care. In addition, nurses, physical therapists, exercise physiologists and dietitians help Center patients with other aspects of treatment. To test medications and other therapies, the hospital holds clinical research trials that may yield advances in preventing and treating osteoporosis and other bone diseases.

Dulipsingh advised Mercier to stay on the Fosamax and continue drinking milk, taking supplements and monitoring her bone density. Active in the community, Mercier has never had time to exercise, but she’s determined to make the time to walk at least three times a week to fulfill the recommendation for weight-bearing exercise. Her advice to others: Learn about osteoporosis and ask your doctor if you should be screened. “I’m so glad my doctor was so on top of things, because I never would have asked for the bone density scan,” she says. “Yes, I’ve had some ups and downs with my density levels, but if I hadn’t started treatment when I did, who knows where I’d be now?”

Sidebar
Risk factors for osteoporosis
Risk factors that increase the likelihood of developing osteoporosis and fractures include:
• Current low bone mass
• Being female
• Being thin and/or having a small frame
• Advanced age
• A family history of osteoporosis or history of fracture in a relative
• Estrogen deficiency due to menopause, especially early or surgically induced
• Low lifetime calcium intake or vitamin D deficiency
• Certain medications (corticosteroids, chemotherapy, anticonvulsants and others)
• Low testosterone levels in men
• An inactive lifestyle
• Current cigarette smoking or excessive use of alcohol
• Being Caucasian or Asian (although African Americans and Hispanic Americans are at significant risk as well)

Sidebar
Osteoporosis is one of the most common — and preventable — diseases. A few lifestyle changes can keep your skeleton strong:
• Reduce your risk factors. Quitting smoking is particularly important.
• Perform weight-bearing exercise – walking, dancing, lifting weights. (While swimming and cycling are great cardiovascular exercise, they’re not weight-bearing.)
• If you’re over 65, menopausal or have any of the osteoporosis risk factors, get screened! The sooner you start treating bone loss, the less you’ll lose.
• Adults should get 1,000-1,200 mg of calcium daily. Food is the best source, but most Americans don’t get enough calcium from their diets. You may need calcium-fortified foods and/or calcium supplements to make up the difference.
• If you do take calcium supplements, spread them out. Calcium is absorbed best when taken 500 mg or less at a time.
• Adults should get 800-1,200 international units (IU) of vitamin D daily. Vitamin D is manufactured in the skin following direct sun exposure, so exposing the hands, arms and face to the sun 10-15 minutes three times a week (depending on your skin sensitivity) is enough tomeet the body’s vitamin D needs. If you can’t spend time in the sun, take supplements or get vitamin D through your diet (major food sources include vitamin D-fortified dairy products, egg yolks, saltwater fish and liver).

Source: National Osteoporosis Foundation, www.nof.org