OSTEOPOROSIS…FACTS AND STRATEGIES FOR MANAGEMENT

By Anna DiMarco, Senior Physiotherapist

WHAT IS OSTEOPOROSIS ?

Bone is living tissue, and as such, it is constantly being broken down and regenerated quietly throughout our lifespan.  Osteoporosis is not a normal process of aging, but rather it is a disease characterized by low bone mass and deterioration of bone quality, predisposing one to fractures.  These fractures can occur anywhere on the skeleton but the most common osteoporotic fragility fracture sites are the wrist, the hip and the spine. 

Osteoporosis  has become mistaken or perhaps ‘accepted’ as a normal process of aging due to its high rate of occurrence in post-menopausal women and its growing rate of occurrence in older men. 

Over 80% of all fractures in those over 50 years old are caused by osteoporosis. One  in  three women and one in five men will sustain an osteoporotic fracture in their lifetime. Unfortunately, fewer than 20% of Canadians who develop an osteoporosis related fracture receive a bone mineral density screening test or an osteoporosis management strategy within one year of their fracture. This “gap in care” leads to an increased risk of further fractures with the potential for more disability, and an increased financial burden on both the individual sustaining the disabling fracture and on the healthcare system itself. 

WHY DO WE LOSE BONE MASS AS WE AGE ?

As a general rule, during our younger years (childhood into young adulthood) our bodies build more bone than that which gets broken down and thus, we build up to our maximum bone density capacity during this period. Between the ages of 25 and 50, our bodies break down old bone tissue and rebuild new bone tissue at a relatively equal rate leading to a relatively stable bone density situation during this stage of life. As we age further, this bone remodelling process becomes negatively imbalanced due to hormonal changes, cellular aging and loss of muscle mass, resulting in bone resorption (breaking down) occurring at a faster rate than new bone can be formed. 

WHY DO SOME OF US LOSE BONE DENSITY AT A FASTER RATE or AT AN EARLIER AGE THAN OTHERS?

There are many risk factors that may predispose one to greater bone density loss as they age.  These risk factors include both modifiable risk factors (those we can control that are often lifestyle related) and non-modifiable risk factors (those that we do not have capacity to control entirely, such as medical conditions, family history, etc)

1. Low peak bone mass in early adulthood 

2. Genetics and Family history of osteoporosis

3. body type (small frame)

4. Chronic medical conditions that impact nutrient absorption (Celiac’s, Chron’s, Irritable Bowel Syndrome, undiagnosed food intolerances, Hyperthyroidism, Lupus, etc)

5. Hormonal Imbalances (Low estrogen in women, early natural or surgical menopause with no hormone replacement therapy, low testosterone, prostate cancer treatments via hormones, etc )

6. Medication side effect (steroids, seizure medications, cancer drugs, radiation treatment locally)

7. Alcohol consumption…regular consumption of > 2  drinks per day increases risk of osteoporosis

8. Smoking history….as few as 10-15 cigarettes per day can impact bone density with damage linked directly to lifetime exposure .  However, smoking in teen and early adult years has greater negative impact as it can interfere with maximum bone density building capacity 

9. Nutritional deficits (calcium, vitamin D, potassium, protein and possibly vitamin K)

10. Sedentary lifestyle or prolonged inability to weight bear due to illness or injury

11. Eating disorders 

PREVENTION IS THE BEST STRATEGY FOR MANAGEMENT

Bone health is important at every age and stage of life, but it is critically important in childhood and adolescence when bones are still developing and we are laying down the foundation for our future bone health.  Most of us will reach our peak bone mass (strength and density) by approximately age 30.  It is therefore critical that our bone health behaviours are optimized from an early age, that we are aware of our own non-modifiable (genetics, medical conditions, medications) and lifestyle risk factors (inactivity, poor diet, excess alcohol etc) and that we collaborate with our primary care physicians regarding appropriate screening for bone density via DEXA scanning and bloodwork. If we are at higher risk of osteoporosis for any reason, we can request DEXA scanning to be performed earlier than the government recommended ages of 65 for women and 70 for men.

HEALTHY BONE BEHAVIOURS:

1. Risk Factor Assessment : be well informed regarding your personal risk factors for osteopororosis, including both modifiable / lifestyle risk factors and non modifiable ones. You can take the KNOW YOUR RISK QUIZ by OSTEOPOROSIS CANADA here at this link below.  It is a great starting point from which to collaborate with your primary care physician regarding further assessment and may highlight your personal need to address some modifiable risk factors. 

https://osteoporosis.ca/risk/

2. NUTRITIONAL TUNE UP : Ensure you are taking in adequate amounts of:      

A) Calcium

Calcium is critical for bone health, giving bone its structure and its strength. It is also a critical mineral for proper heart health, nerve health and muscle function. Because our bodies do not produce calcium, we must take calcium in through our diets.  If we are not taking in enough calcium, our bodies will pull calcium out of our bones to meet the needs for our various calcium-dependent systems and this can increase the risk of osteoporosis. 

Appropriate calcium intake is also critical if one is taking osteoporosis building medication.  Check with your primary care provider to ensure you are doing what is best for your particular situation and medical history. 

                    B) Vitamin D

Vitamin D helps your body absorb Calcium.  One in five Canadians will be vitamin D deficient, with rates spiking during the late fall and winter months when up to 97% of the population suffer from inadequate levels.  This occurs due to our location in the Northern hemisphere.  Our northern latitude means that the Vitamin D that we produce through our skin’s exposure to the sun’s UVB rays are not adequate through the winter and cooler months (angle of the sun will not produce the UVB we need to stimulate vitamin D) and we will quickly burn through any “stores’ we may have produced during our beautifully sunny summer months. As well, many of us will remain deficient in the summer time as well if we work indoors, wear sunscreen or avoid sun exposure.

It is best to speak with your primary care practitioner if you have concerns about your vitamin D levels and are interested in meeting the recommended daily dose. 

                     C) Protein

Protein is necessary to build and repair bone tissue and helps to keep our muscles strong. Diets that include recommended amounts of protein are associated with greater bone mass and fewer fractures when calcium intake is adequate.

SPEAK TO YOUR PRIMARY HEALTH CARE PROVIDER REGARDING YOUR NUTRITIONAL NEEDS AND DAILY RECOMMENDED DOSAGES

3. MOVEMENT TUNE UP: are you getting enough exercise, the right amount of exercise, and is the exercise intensity enough to help maintain and / or stimulate bone growth ? 

The latest research is suggesting that sedentary behaviour and physical activity are independent factors that influence skeletal health….ie. emerging evidence is suggesting that prolonged sitting and inactivity can harm skeletal health even in those individuals who engage in regular physical activity.  The International Osteoporosis Foundation (IOF) is suggesting that clinical practice and public health policy should address both : reducing prolonged sedentary time and encouraging regular physical activity. 

A quick summary of what will help to maintain bone density:

1. Frequent movement breaks (every 30-45 min) if you have a sedentary job, are prone to sitting in front of a screen for hours on end at home,  or are unable to participate in regular physical activity levels.  This may include use of stand up desks, frequent mini walking breaks, walk-and-talk meetings, active commuting (park further away, ride bike, get off bus early, etc), break up screen time with walking, stretching, lifting weights during commercial breaks if watching tv/movies, etc.

2. Weight bearing exercises: the weight of your body creates a force that will help to stimulate bone health. Examples of weight bearing activities include: Brisk walking (3.1-3.7mph pace), dancing, jogging, jumping, heel drops, racquet sports, stair climbing.  The greater the ground reaction force, the greater the impact on bone density.  Walking loads the bones with 1-2x your body weight and may help to maintain bone density but will not provide enough stimulus to build new bone and therefore does not improve bone density.  Jumping, running and quick starts and stops will produce a mechanical load that is equivalent to  3-4x your body weight and will improve bone density. 

3. Resistance /Strength Training: adding resistance to movement and making the muscles work harder and become stronger.  This puts stress on the bones and helps the bones to become stronger as well. Strength training exercises can involve the use of your own body weight with or without additional weight (squats, push ups for example), use of weight machines that isolate muscles, free weights/ kettlebells/ sandbags, and resistance bands.

4. Balance Training: to help with fall prevention

5. Jumping OR Heel drops: Jumping and Heel drops will provide targeted high impact ground resistance forces that will stimulate bone remodelling and increase bone mineral density.

Not everybody is able to immediately adopt an aggressive bone building exercise regimen.  Some bodies have to move more slowly and cautiously into this realm because of their osteoporosis situation or other risk factors for fracture.  For this reason, it is wise to receive medical clearance before adopting a new exercise regimen.  Once cleared for new activities, seek the guidance of a physiotherapist to assist you with creating an appropriate movement strategy for your bone health concerns!