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April 29, 2002
News this month Results from the nation's largest study of osteoporosis, the National Osteoporosis Risk Assessment (NORA), published in the Journal of the American Medical Association, indicate many postmenopausal women have thinning of the bones—and don't know it. Nearly one out of every two women tested had undetected low bone-mineral density.
In the largest study of osteoporosis conducted to date in the U.S., more than 200,000 healthy women age 50 and older were recruited from doctors' offices and underwent bone density screening. Researchers report nearly one out of every two women tested had undetected low bone-mineral density. Seven percent of the women had such severe depletion of bone mass that they were diagnosed with osteoporosis. In addition, about 40 percent had low bone density but were not osteoporotic. In one year, women with osteoporosis were four times more likely to suffer a fracture compared to those with healthy bones.
Researchers followed up with about 75 percent of the participants after the initial diagnosis and found that in one year, women with osteoporosis were four times more likely to suffer a fracture compared to those with healthy bones; the fracture rate in women with low bone density was double that of women with normal bones. “In our study we found almost half of the postmenopausal women sitting in doctors' offices who have never been assessed for osteoporosis had low bone mass and were at increased risk of fractures,” said Ethel Siris, MD, lead author and medical director of the NORA research program. “Given the physical and financial toll caused by osteoporotic fractures, these findings underscore the tremendous need for both women and their health care providers to better identify and manage osteoporosis.” Who's most at risk?
Dr. Felicia Cosman, clinical director of the National Osteoporosis Foundation, said the findings are not surprising. Previous estimates suggested that about eight million American women have osteoporosis and 14 million more have low bone mass. Fractures were found to be more common among women with risk factors such as smoking, older age and a family history of osteoporosis. But many other women thought to be at low risk also had broken bones, including African American women. The study included 18,000 African American women, who previous studies
have shown face a lower osteoporosis risk than whites. The prevalence
of low bone mass and osteoporosis among them was still significant:
32 percent and 4 percent respectively. 
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Effective interventions for osteoporosis are available This study is one of only a handful published recently that look at the prevalence of osteoporosis in the U.S. Despite all the media attention to this topic, many women still do not consider this as a health issue they need to address. Unlike mammograms and Pap smears, bone density tests are not done routinely and so many women are at risk without realizing it. The reality is one in two Caucasian women will have an osteoporotic fracture in her lifetime. There are 300,000 hip fractures annually, up to 20 percent of which lead to death within a year and, among those who survive, many never regain full independence. The good news is that there are effective interventions for women with osteoporosis, so identifying and screening at-risk women is an important first step. As the study reported, those most at risk include women who have had fractures; those whose female relatives have had broken bones or stooped posture; women who experienced estrogen deficiency related to menopause before age 45 or due to conditions such as eating disorders; Caucasian and Asian women; those who have taken glucocorticoid medications for prolonged periods of time and women of advanced age. “Our skeleton is like a retirement account for minerals, but…we
can deposit bone faster than we withdraw it only during our first three decades.”
What causes loss of bone density? When we're young, bone building prevails. Bone mass peaks by about age 25 to 30, then bone breakdown begins to outpace formation and bone density declines. Our skeleton is like a retirement account for minerals, but in our skeletal "account" we can deposit bone faster than we withdraw it only during our first three decades. After that, particularly during the first few years after menopause, withdrawals are greater than deposits. About 65 to 75 percent of bone mass is genetically determined, but exercise and nutrition can help. Lifelong weight lifters have stronger bones. Also race influences bone mass—African American women have the strongest bones; Asian women the least strong. Bone density and fractures “Exercise improves balance and strength and can be a powerful weapon against falling and fractures.”
Bone density is a powerful risk factor for hip fracture, but falling is equally important. We tend to put women on lots of drugs to protect their bone mass and forget about reducing their risk of falling. Hip protectors are a very effective way to reduce hip fractures for people who are at high risk of falling—those with poor eyesight, with Parkinson's disease, diabetes or stroke sufferers. Another way to reduce risk that doesn't get much press is exercise. Most people exercise at a level that produces only a modest effect on bone mass, but exercise improves balance and strength and can be a powerful weapon against falling and fractures. Muscular strength, particularly in the abdomen and back, can take some of the pressure off our spines and reduce spinal fractures. Osteoporosis diagnosis With measurements between 1 and 2.5 SDs below normal, bone mass is considered low. Such patients have osteopenia and are at risk of becoming osteoporotic. A score of 2.5 SDs or more below normal indicates osteoporosis. Osteopenia If they are post menopausal and not taking estrogen or other anti-osteoporotic medications, I repeat the bone density test in 12 to18 months. If their bone density shows a decline, I would consider medications. But all medications have expense and potential side effects attached, so I would ensure there was a clear benefit first. “The first true bone-forming drug should be available before the end of 2002.”
Drug treatment options Estrogen has not been studied as carefully as these other drugs even though it has been used for a long time. Most of the evidence indicates that long-term estrogen use reduces the risk of both spine and hip fractures. Although these drugs increase bone mass only by a modest 5 to 10 percent, they reduce the risk of fracture by a very significant 40 to 50 percent. At one time I considered osteoporosis risk to be an important argument for the use of HRT, but as we learn more about the long-term effects of HRT and since alternatives to estrogen are now available, I am less inclined to do that. Each woman needs to evaluate with her physician whether she is a good candidate for HRT. There is a new drug that should be available before the end of 2002
called Forteo. It is the first true bone-forming drug, and it will
help us care more effectively for women who have not responded well
to other treatments and patients who have osteoporosis because of
long-term steroid use. Forteo is administered daily by injection.
In clinical trials, it has produced significant increases in bone
mass within 12 to 18 months. Dr. Insogna is the director of the Yale Bone Center, an attending endocrinologist at Yale-New Haven Hospital and a professor of medicine at the Yale University School of Medicine. |
