Thin, fragile struts of bone, called trabeculae, are characteristic of severe osteoporosis. Image courtesy of David Gregory and Debbie Marshall, Wellcome Images.
Boning Up on Osteoporosis
Our bones are living tissues in a constant state of healthy repair and renewal. When that doesn’t happen or doesn’t happen enough, bones can become more hollow and vulnerable to sudden fractures and breaks, which can lead to even more serious health complications.
The condition is called osteoporosis, and it’s a national affliction: More than 44 million Americans currently suffer from low bone density (LDB) or osteoporosis. As our population ages, that number will likely grow. The National Osteoporosis Foundation estimates half of all Americans over the age of 50 will suffer from (LBD) or the disease itself by 2020.
Many things cause or contribute to osteoporosis. The biggest factors are age and gender. The majority of people with osteoporosis are older and female. It’s estimated that one in two women and one in four men over the age of 50 will break a bone due to osteoporosis.
A lot is known about osteoporosis, but the disease can still be pretty confusing. For example, the Institute of Medicine (IOM), which advises the federal government on health issues, has recommended that women older than 50 supplement their diets with calcium and vitamin D, but the U.S. Preventive Services Task Force (USPSTF), another health advisory group, recently said there’s no evidence that supplementation makes a measurable difference.
Q: Where do you stand on the issue of vitamin D and calcium supplements? The IOM says women older than 50 should consume 1,200 milligrams of calcium daily to promote bone health, but the USPSTF has said low supplemental doses of calcium or vitamin D are ineffective in helping prevent fractures and the evidence for higher doses is unclear.
Kado: The USPSTF is correct in concluding that the available evidence does not support calcium or vitamin D supplementation as effective for preventing fractures. But it is clear that having adequate calcium in the diet and sufficient vitamin D are important in maintaining bone health. My recommendation (in line with current FDA regulations) is that older women and men should take about 1,200 mg of calcium daily. The average American consumes about 500 to -600 mg, so I usually advise that additional calcium supplementation of about 600mg is ideal.
With regard to vitamin D, having sufficient levels is important for optimizing the amount of calcium in the bone. This vitamin helps ensure adequate calcium absorption from the gut and also favors keeping a good balance of calcium in the bone. I generally recommend 800 to 1,000 IU daily of vitamin D3.
Q: What about findings that suggest high calcium intake may increase the risk of heart disease in women?
Kado: Even prior to recent publications suggesting that women who take calcium supplementation greater than 800 mg daily are at increased risk of heart attacks and mortality, there were some physicians who voiced belief that taking calcium could lead to calcium build-up in the arteries. However, this assumption is simply an hypothesis with no sound evidence to support it. My personal view is that patients should be aware of their daily calcium intake, try to achieve at least 600 mg and generally not take more than 800 mg daily in supplements.
Q: How much of a problem is vitamin D deficiency, particular in sunny places like San Diego?
Hofflich: Studies have shown that even places like San Diego still have a high level of vitamin D deficiency. In 2008, when vitamin D became a ‘hot topic,’ I did order levels on many of my patients and found a high level of vitamin D deficiency/insufficiency. One issue is that people wear sunscreen, which reduces vitamin D absorption because they are not receiving adequate sun exposure. This is likely a major reason for some vitamin D deficiency. However, sunscreen is important because it prevents skin cancer. That’s why patients should supplement with vitamin D, if needed.
Q: It seems like some people view supplements as a way to counter deficiencies in other factors related to osteoporosis, such as sufficient exercise, a healthy weight, no smoking, etc. Can patients effectively maintain bone health emphasizing some factors more than others?
Hofflich: The most important preventive strategies for maintaining bone health are no smoking, less than three small glasses of alcohol daily, at least 30 minutes of weight-bearing exercise daily and adequate calcium and vitamin D intake.
There are many factors that contribute to bone loss that cannot be modified, such as increasing age, certain medications and genetics, but the list above can be changed and it’s good for preventing osteoporosis.
Q: A small study last year found that moderate alcohol intake appears to support bone health by slowing bone turnover, but most guidelines seem to suggest minimal alcohol.
Kado: It is true, some – but not too much alcohol – is good for us. What is too much? For older women, no more than 2 drinks daily; for older men, no more than 3 drinks daily. That’s a reasonable rule for most people. However, if there is a family history of alcoholism or substance abuse, recommending alcohol is a slippery slope because drinking too much can cause a multitude of problems, one of which is falling down and fracturing bones.
Q: In your practices, what tend to be the most common risk factors for osteoporosis? Which factors are toughest to mediate?
Hofflich: The major ones, in no particular order, are history of prior spontaneous fractures after the age of 50, a parent with a hip fracture, gender, age, underweight, rheumatoid arthritis, glucocorticoid use, smoking, excessive alcohol consumption and dietary deficiencies.
Kado: The toughest to mediate is family history - we can’t help. Steroid use is generally tough because there are usually good reasons for why patients take steroids. And weight loss. In general, people tend to worry about losing weight versus the other way around.
Q: Any take-away messages?
Hofflich: The best thing is to be pro-active about your bone health and talk with your primary care physician. It’s very important that patients discuss their bone health with their doctor at each physical or on an annual basis. All women over the age of 65 should have a bone density scan; men over the age of 70, as recommended by the National Osteoporosis Foundation.
Kado: Prevention is the best strategy and as a geriatrician, I have learned from my older patients (those 85 and older) that eating well, being actively engaged in daily life and accommodating life’s challenges with a sense of humor and humility are all important.
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