Osteoporosis - Bone Health

What You Need to Know

Introduction

• Increasing life expectancy: Many women now spend over one-third of their lives postmenopausal.
• Hormonal influence: Estrogen deficiency leads to accelerated bone loss and reduced calcium absorption.
• Greatest bone loss: Up to 3–5% annually in the early postmenopausal years.
• High prevalence:
  • ~33% of women aged 50–60 affected
  • 50% of women over 80 have osteoporosis
• Fracture risk:
  • Lifetime risk for osteoporotic fracture in 60-year-old women: ~44%
  • Most affected: vertebrae, hip, distal forearm
• Health consequences:
  • Increased morbidity and mortality (20–30% 1-year mortality after hip fracture)
  • Loss of independence and quality of life

Definition & Prevalence

• Definition (NICE 2012): Systemic skeletal disorder characterized by:

  • Low bone mass
  • Microarchitectural deterioration of bone tissue
  • Increased fragility and fracture risk

• “Silent disease” – often asymptomatic until fracture occurs

• Bone physiology:

  • Living tissue: protein matrix + minerals
  • Continuous remodeling: resorption vs. formation
  • Goal: maintain good bone mineral density (BMD)

• Peak Bone Mass (PBM):

  • Critical for long-term bone health
  • 10% more PBM = ~30% fewer hip fractures
  • Age window:
    • Hip: 16–19 years
    • Spine: 30–40 years
  • Influencing factors: genetics, exercise, sunlight, calcium intake

• Hormonal regulation:

  • Hormones involved: PTH, calcitonin, vitamin D, estrogen

• BMD changes (SWAN Study):

  • Pre-/early perimenopause: minimal loss
  • Late menopause & early postmenopause: accelerated loss
  • Lifetime loss:
    • ~50% trabecular bone
    • ~30% cortical bone
    • ~50% of that in the first 10 years postmenopause

Diagnostics

First steps:

• Medical history: identify risk factors & comorbidities
• Symptoms:
  • Fractures from minor trauma
  • Back pain, height loss, kyphosis
  • Generalized bone/joint pain
• Physical exam:
  • Posture, height measurement
  • Rule out other causes of pain or posture change

Imaging & BMD:

• X-ray / CT / MRI
• Bone Density Scan (DXA) – Gold Standard:
  • Sites: lumbar spine, hip, possibly forearm
  • T-score classification (WHO):
    • ≥ –1.0: Normal
    • –1.0 to –2.5: Osteopenia
    • ≤ –2.5: Osteoporosis
    • ≤ –2.5 + fracture: Severe osteoporosis

Other Tools:

• FRAX®: 10-year fracture risk calculator
  • Hip fracture risk > 3% or major fracture > 20% → treatment indicated
• Laboratory tests:
  • Calcium, phosphate, vitamin D, thyroid, liver, kidney, bone markers

Quantitative Assessment Tools

1. QUS (heel ultrasound) – predictive but not diagnostic
2. BTM (bone turnover markers) – for treatment monitoring
3. qCT – precise, 3D imaging of trabecular & cortical bone
   • High radiation and cost
   • Not for routine screening

→ DXA remains the reference method for diagnosis and follow-up

Therapy

Non-Pharmacological

1. Nutrition

• Calcium:
  • Recommended: 1,200 mg/day
  • Ideal: half via food, rest via supplements
  • Max: 2,000 mg/day
• Vitamin D:
  • Recommended: ≥ 800 IU/day
  • Supports calcium absorption
  • Supplementation often necessary
• Protein intake:
  • 1 g/kg body weight per day
• Calcium-rich foods:
  • Dairy, green veggies, legumes, nuts, fortified cereals

2. Exercise

• At least 3x/week, 30 minutes each
• Types:
  • Weight-bearing (walking, dancing, stairs)
  • Strength training
  • Balance (Tai Chi, stability exercises)
• Benefits:
  • ↑ BMD
  • ↓ fracture risk

3. Fall prevention

• Home adaptations:
  • Good lighting, non-slip mats, grab bars
• Additional measures:
  • Vision correction
  • Hearing aids
  • Proper footwear
  • Hip protectors for high-risk individuals

4. Lifestyle changes

• Quit smoking
• Reduce alcohol & caffeine
• Stay physically and socially active

Pharmacological Therapy

Goal: Prevent fractures by: Reducing resorption (antiresorptive) and Stimulating formation (anabolic)

A. Antiresorptives:

• Bisphosphonates
• Denosumab
• SERMs
• MHT (Hormone therapy)
• Calcitonin

B. Anabolics:

• Teriparatide
• Abaloparatide
• Romosozumab

Selection criteria of Pharmacological Therapy:

• Severity (T-score, fracture history)
• Fracture risk (FRAX)
• Age, kidney function, patient preference
• Side effects, cost

Conclusion

Public Health Relevance:

• Chronic disease with high morbidity and mortality
• 1 in 3 women over 50 will suffer an osteoporotic fracture

Prevention & Early Detection:

• Promote peak bone mass by age 30
• BMD testing from age 65 or earlier if risk factors exist
• Combine BMD with FRAX for better assessment

Effective Prevention:

• Calcium- and vitamin D-rich diet
• Regular strength and balance exercises
• Smoking cessation, moderate alcohol
• Fall prevention is key

Long-term management:

• Ensure adherence via education and support
• Regular DXA monitoring
• Adjust treatment as needed