Content

Introduction

Osteoporosis is a disease that weakens bones, making them fragile and more prone to fractures.

In Italy, according to the latest ISTAT survey, only 4.7% of the total population and 17.5% of people over sixty-five years of age declare to have this disease. The result is similar to that which emerged from the most recent multicentre epidemiological study national, AESOP, according to which 23% of women over 40 and 14% of men over 60 have osteoporosis.

Fractures (partial or total fractures of the bone) caused by this disease occur mainly in the areas of the wrist, vertebrae and in the part of the femur close to the hip (proximal part of the femur). However, they can also affect the arm, ribs or pelvis.

Osteoporosis usually does not show signs of its onset and is often ascertained (diagnosed) only after a fracture that can occur after a fall, even a trivial one. During childhood, bones grow and repair themselves very quickly, from 35 years of age. from age onwards this process is very slow, particularly in menopausal women, and in some people it can cause fractures (Video).

If the treating physician suspects that a patient has osteoporosis, he or she may prescribe an assessment, computerized bone densitometry or mineralometry (MOC), useful for assessing the risk of a fracture.

The treatment of osteoporosis is based on the prevention of fractures, on their treatment if they should occur and on the use of drugs to strengthen the bones. The decision on the type of treatment will depend on the outcome of the investigations prescribed by the doctor and his assessment of the magnitude of the risk based on a number of factors, such as age and the results of the MOC.

People at risk of developing osteoporosis should take precautions to keep their bones healthy, including:

  • getting regular exercise
  • follow a healthy diet, which includes foods rich in calcium and vitamin D
  • change lifestylesfor example, quitting smoking and reducing alcohol consumption

Having osteoporosis does not mean that you will definitely have a fracture.

You can follow some measures to reduce the probability of a fall such as, for example, the elimination of possible dangers, or obstacles, present in the house that could cause you to stumble and the periodic execution of eye examinations and hearing tests.

Symptoms

Osteoporosis develops slowly over several years.

Often there are no signs or disorders (symptoms) that herald the onset of the disease until a trivial fall, or a sudden bump, causes a bone fracture (total or partial breakage of the bone).

The injuries that occur most frequently in people with osteoporosis are:

  • wrist fracture
  • hip / femur fracture
  • vertebral fractures

In severe cases, even a cough or sneeze can cause a rib fracture or partial collapse of one of the bones in the spine.

In older people, a broken bone, such as a hip fracture, can be a serious problem leading to long-term disability.

Although a fracture is usually the first sign of osteoporosis, some older people develop a characteristic hunched (forward bent) position caused by the bones of the spine which, being fractured, can no longer support the weight of the body. Vertebral fractures are the most common cause of long-term (chronic) pain associated with osteoporosis. The disease usually causes no pain until it becomes advanced enough to break the bone.

Causes

Osteoporosis makes bones less dense and more fragile, and some people are more at risk than others of developing osteoporosis. During childhood, bones grow and repair very quickly, but as we get older this process is very slow.

Bones stop growing in length between 16 and 18 years of age while the amount of mineral salts present in the bone, which determines its compactness (bone density), continues to increase until the age of 30 and then decreases. from 35 years onwards. This decline is much more rapid in women, especially in the first few years after menopause (Video).

The loss of bone tissue, and therefore the decrease in its density, is a normal process of aging but in some people it occurs faster than normal and this, in some cases, can cause osteoporosis and an increased risk of fractures. in young people and children.

Factors that increase the risk of developing the disease include:

  • inflammatory diseases, such as rheumatoid arthritis, Crohn's disease, and chronic obstructive pulmonary disease (COPD)
  • diseases affecting the glands that produce hormones, such as an overactive thyroid gland (hyperthyroidism) or parathyroid gland (hyperparathyroidism)
  • family members with osteoporosis (family history of osteoporosis), especially having a parent who has had a hip fracture
  • long-term use (for more than three months) of some oral steroid medications (orally), widely used, for example, for diseases such as arthritis and asthma, which affect hormone levels and bone density
  • malabsorption, such as that occurs in celiac disease and Crohn's disease
  • excessive use of alcohol and smoking
  • removal of the ovaries
  • eating disorders, such as anorexia and bulimia
  • lack of regular exercise
  • body mass index (BMI) of 19 or less
  • some drugs used to treat breast cancer and prostate cancer
  • long periods of physical inactivity, such as prolonged bed rest

Women
Women are more at risk of developing osteoporosis than men because the hormonal changes that occur in menopause directly affect bone density.

Female hormones (estrogen) are essential for bone health. After menopause (when menstrual cycles stop), estrogen levels decline. This can lead to a rapid decrease in bone density.

Women are even more at risk of developing osteoporosis if they have:

  • early menopause (before 45 years of age)
  • hysterectomy (surgical removal of the uterus) before the age of 45, especially if the ovaries are also removed
  • amenorrhea (absence of menstruation) for more than 6 months as a result of excessive exercise or a too strict diet

Men
In most cases, the cause of osteoporosis in men is unknown. However, it may be related to the male hormone (testosterone) that helps maintain healthy bones.

Men continue to produce testosterone into old age, but the risk of osteoporosis increases in those with low levels.

In about half of men, the exact reason for low levels of this hormone is unknown. Known causes include:

  • use of some medications such as, for example, glucocorticoids
  • alcohol abuse
  • hypogonadism, a disease that affects the testicles and causes low testosterone levels

Main risk factors
In addition to the causes already described, there are other factors that can affect bone density. People who have a disease of the hormone-producing glands, for example, may have a higher risk of developing osteoporosis.

Hormone-related diseases that can trigger the disease are:

  • hyperthyroidism (overactive thyroid)
  • disorders of the adrenal glands, such as Cushing's syndrome
  • reductions in sex hormones (estrogen and testosterone)
  • disorders of the pituitary gland (or pituitary, a gland located in the brain that produces hormones that regulate sexual function and affect the functioning of other glands such as the thyroid and adrenals)
  • hyperparathyroidism (hyperactivity of the parathyroid)

Diagnosis

Osteoporosis is often found (diagnosed) after the already weakened bones have sustained a fracture.

If you are at risk of developing osteoporosis, your family doctor may prescribe a bone densitometry, better known as MOC (computerized bone mineralometry). This is a short, painless investigation that allows you to measure the amount of mineral present in your body. "bone in certain parts of the skeleton (lumbar spine, part of the femur near the hip, wrist) particularly indicative of the presence of osteoporosis.

Currently, the most commonly used methods to perform mineralometry are MOC DXA, which requires the use of a specific X-ray apparatus. Normal X-rays are a useful way to identify fractures, but are not a reliable method for measuring. bone density.

DXA scan
It is a quick, safe, and painless procedure that usually takes about five minutes, depending on which part of the body to investigate.

DXA measures the bone mineral density of the person undergoing it and compares it with that of a healthy young adult and with that of an individual of the same age and gender.

The difference between the measured bone density and that of a healthy young man is calculated as a standard deviation (SD) and is called the T score.

Standard deviation is a measure of variability based on an average or expected value. A T score:

  • above -1 SD is normal
  • between -1 and -2.5 is defined as a decrease in bone mineral density relative to peak bone mass
  • below -2.5 is defined as osteoporosis

Although a DXA scan can help diagnose osteoporosis, the result of bone mineral density is not the only factor determining the risk of a bone fracture.

Age, gender and any previous injuries will need to be considered before deciding whether or not treatment for osteoporosis is necessary.

The family doctor can help you decide what measures to take to improve the health of your bones and, if necessary, suggest safe and effective treatment.

The FRAX calculator
The World Health Organization has developed a calculator that can measure the individual risk of bone fracture at 10 years of age in people between the ages of 40 and 90. The tool is based on bone mineral density and other risk factors, including age and gender. The algorithms used indicate the likelihood of having a hip fracture or a severe fracture of the spine, shoulder or forearm within 10 years.

Therapy

Treatment of osteoporosis includes the prevention and treatment of fractures and the use of drugs to strengthen bones.

Preventing falls and fractures in the elderly
The Ministry of Health and the Istituto Superiore di Sanità have developed a guideline on Prevention of falls from domestic accidents in the elderly which contains the scientific evidence, currently available, on risk factors for falls and effective interventions to prevent them.

Recommendations include:

  • tell the doctor about any falls, even if they have no consequences. It is important that he knows where the fall occurred and why
  • talk to your doctor and remind him which medications you are taking
  • in case of vision problems or difficulty in reading, undergo a specialist examination by the ophthalmologist
  • check that the house you live in does not present obstacles or dangers that could favor falls
  • if you have problems walking, turning and sitting, talk to your doctor to evaluate the opportunity for a specialist visit
  • exercise in moderation, just walk, take the stairs and go dancing

An overview of therapy
Although the "assessment (diagnosis) of osteoporosis is based on the results of the MOC DXA, the decision on the type of treatment to be carried out considers other factors, including:

  • age
  • gender
  • fracture risk level
  • accidents that have already occurred 

In the event that osteoporosis has been ascertained (diagnosed) after a fracture, care should still be taken to reduce the risk of others occurring. It is advisable to ensure that calcium and vitamin D levels are normal and, if necessary , make changes to your diet and / or take supplements (read the Hoax.) It may not always be necessary to take medications.

NICE recommendations
The UK's National Institute for Clinical Excellence (NICE) has developed recommendations on who should take medications for osteoporosis.

Before deciding which medicines to use, a number of factors need to be considered, including:

  • age
  • gender
  • bone mineral density (measured by the T score)
  • risk factors for fractures

NICE summarized the guideline for two groups of people:

  • postmenopausal women who have osteoporosis but have not had fractures (primary prevention)
  • postmenopausal women with osteoporosis who have had fractures (secondary prevention)

Prevention

Everyone's genetic makeup determines the height and strength of the skeletal system but lifestyles, such as diet and exercise, influence the state of health of the bones.

Exercise regularly
Regular physical exercise is essential. After consulting with your doctor and receiving his positive opinion, which is essential before engaging in any physical activity, various types of training can be undertaken gradually and consistently to prevent "osteoporosis and its consequences. To do this, adults between the ages of 19 and 64 should do at least 150 minutes (2 hours 30 minutes) of moderate-intensity aerobic exercise, such as biking or brisk walking, each week. They may also practice muscle-building activities for two or more days a week, working on all major muscle groups, including those in the legs, hips, back, abdomen, chest, shoulders, and arms.

Exercises conducted against gravity
The exercises conducted against the force of gravity are those in which the movement of the body "weighs" on the skeleton. Simple actions such as walking, running, dancing, jumping on the spot strengthen the muscles, ligaments, joints and stimulate bone metabolism.

While practicing these exercises, it is advisable to wear footwear that provides adequate support for the ankles and feet, such as sneakers or hiking shoes..

People over the age of 60 can also benefit from regular exercise done using body weight or by resorting to additional weights (so-called exercise in charge). This type of activity can include brisk walking, running, jumping, or a game of tennis. Conversely, swimming and cycling are not very useful because, since there is no impact of the weight of the body, the movement does not weigh on the skeleton.

Resistance exercises
Resistance exercises, such as push-ups, weight lifting, or the use of equipment in the gym are particularly important for improving bone density and can help prevent osteoporosis. Using muscle strength, they pull (pull) the tendons on the bones which increases their resistance.

Those who join the gym for the first time or return to attend it after some time are usually offered a personalized training program that also includes examples of using the equipment. If you are unsure how to use a piece of equipment or perform a particular exercise, it is always advisable to ask an instructor.

Eat healthy
Eating a healthy and balanced diet is recommended for everyone and can help prevent many serious diseases including diabetes, heart disease, many forms of cancer, and even osteoporosis (read the hoax).

Calcium is important for keeping bones strong. Foods that contain good amounts of it are green leafy vegetables, dried fruit, tofu and yogurt.

Vitamin D is also valuable for bone and tooth health because it helps the body absorb calcium. Vitamin D is found in eggs, milk and oily fish.

A vitamin D deficiency can occur in particular:

  • in people who are homebound or who are particularly frail
  • in people who follow a poor diet
  • in people who cover themselves from sunlight both because they use full-screen sunscreen and because they follow a certain dress code
  • in pregnant or lactating women

People at risk of reduced dietary or lifestyle intake can use a vitamin D supplement.

The Ministry of Health recommends:

  • follow a diet rich in fruits and vegetables which also provides an adequate calcium intake (about 1000 milligrams per day in the first 8 years of life, 1600 mg between 9 and 17 years, 1100 mg between 18 and 30 years. 1000 mg per day for men aged 50-70 years, 1200 mg per day for women over 50 and men over 70) through milk, yogurt, cheese, calcium-enriched foods, calcium-rich mineral waters
  • limit salt intake
  • adequate intake of vitamin D. (800-1000 IU / day) and, if necessary, the use of vitamin supplements if you are over 50 and / or lack vitamin D

Your family doctor will advise you on how to avoid vitamin D deficiency or how to correct it if it is already there.

Exposing the body to the sun
Most vitamin D is produced by the skin in response to ultraviolet radiation from the sun. A short exposure to the sun without any protection throughout the summer (May to September) should be enough to provide enough vitamin D for the whole year.

The sunlight triggering the production of vitamin D, which favors the absorption of calcium by the body, helps to strengthen the teeth and bones and, therefore, to prevent osteoporosis. However, it is recommended not to exceed more than 10 minutes of exposure twice a day, avoiding the central hours of the day (from 11 to 15), due to the health risks associated with ultraviolet radiation (from burns to skin tumors such as malignant melanoma).

Other factors
Other lifestyle-related factors that can help prevent osteoporosis are:

  • stop smoking since smoking increases the risk of developing osteoporosis
  • limit alcohol intake. The quantity not to be exceeded in order not to incur greater health risks has been identified in about 10 grams of alcohol per day, in other words, less than a glass of wine or a bottle of beer; drink less than 1 U.A. per day (i.e. less than 12 grams of alcohol, equivalent to a small glass of wine or a can of beer with 4.5 °) is considered lower risk behavior; absolutely to avoid alcoholic "binges" (also called binge drinking) which consist in the "intake of excessive quantities of alcohol on a" single occasion

Prevent falls
Making some simple changes around the house and identifying sources of danger, such as flying lines, can help reduce the risk of a fall and, therefore, a fracture. Also, it is advisable to make sure that the carpets are safe (if not, avoid keeping them), always use rubber mats under the sink and in the bathtub to prevent slipping, check your sight and hearing regularly.

Some elderly people may need to wear special protections on their hips to cushion a possible fall.

To avoid them, the Ministry of Health recommends:

  • use of canes or walkers
  • use of rubber-soled shoes
  • avoid keeping rugs in the house
  • achieve good lighting in the house
  • provide support points in the house, especially in the bathroom

Your family doctor can offer help and advice on lifestyle changes.

Obtain support for those living with osteoporosis
People with osteoporosis can take measures to mitigate the consequences of a fall and facilitate recovery:

  • hot baths and cold packs
  • transcutaneous electrical nerve stimulation (TENS) through a small battery-operated device used to stimulate nerves and reduce pain
  • relaxation techniques

If you have any doubts or concerns about having to live with a long-term illness, it is advisable to speak with your doctor, specialist and psychologist.

Bibliography

NHS. Osteoporosis (English)

EpiCentro (ISS). Osteoporosis

In-depth link

Ministry of Health. Osteoporosis

Ministry of Health. Diagnostic and therapeutic appropriateness in the prevention of fragility fractures from osteoporosis. Notebooks of the Ministry of Health. 2010, n. 4

Italian Society of Osteoporosis of Mineral Metabolism and Skeletal Diseases (SIOMMMS)

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