Moji Saberin-Williams, M.D. Paoli Hospital Obstetrician/Gynecologist Osteoporosis Moji Saberin-Williams, M.D. Paoli Hospital Obstetrician/Gynecologist

Osteoporosis The Most Common Bone Disease Characterized by low bone mass and deterioration of bone structure Not a natural part of aging Increased risk for women, post-menopausal, over age 65 All races, sexes, and ages are susceptible Preventable and treatable!

Frequency of Common Medical Events in Women 1,500,000 500,000 1,000,000 2,000,000 Osteoporotic Fractures 1. Riggs, B.L., and Melton, L.J. III, Bone 17(5)(Suppl.):505S-511S, 1995 2. Heart and Stroke Facts: 1996 Statistical Supplement, American Heart Association 3. Cancer Facts & Figures—1996, American Cancer Society * annual incidence all ages ** annual estimate women 29+ † annual estimate women 30+ ‡ 1996 new cases, women all ages * 513,000 Heart Attack ** 228,000 Stroke † 184,300 Breast Cancer ‡ 750,000 vertebral 250,000 other sites 250,000 forearm 250,000 hip Annual incidence of common diseases

Osteoporosis: Definition A condition of skeletal fragility characterized by compromised bone strength predisposing to an increased risk of fracture Normal Bone Osteoporosis NIH Consensus Development Conference Statement, on Osteoporosis Prevention, Diagnosis, and Therapy, 2000. Source: Dempster DW, et al. J Bone Miner Res. 1986:1:15-21; Reprinted with permission from the American Society of Bone and Mineral Research

Entire Skeleton Is at Risk for Fractures NIH/ORBD National Resource Center. October 2000.

250,000 Hip Fractures Each Year Up to 24% excess mortality within 1 year Nearly 65,000 American women die from complications of hip fracture each year 50% of hip fracture survivors are permanently incapacitated3 20% of hip fracture survivors require long-term nursing home care4 1. Ray NF et al. J Bone Miner Res 1997;12:24-35 2. Col NF et al. JAMA 1997;227:1140-1147 3. Consensus Development Conference. Am J Med, 1993;94 646-650 4. Chrischilles EA et al. Arch Intern Med 1991;151

EPIDEMIOLOGY Major Health threat in an estimated 44 Million people ages 50 and older 1 in 2 women and 1 in 6 men over 50 will have an osteoporosis-related fracture 1 out of 3 women age 90 have had a hip fracture

Hip Fracture Incidence in 1997 * Fracture rate per 1000 patient-years for 5-year intervals of age, from U.S. National Inpatient Sample database composed of >13 million white women, age 70-85+.

Osteoporosis Risk Factors Non-modifiable Previous fragility fracture History of fracture in a first degree relative Increased age Female gender Caucasian or Asian Premature graying of hair Modifiable - Estrogen deficiency - Propensity to fall - Impaired vision - Calcium deficiency - Vitamin D deficiency - Low body weight - Physical inactivity - Excessive Alcohol consumption NOF guidelines – 2000

How do I know if I have osteoporosis? Bone Mineral Density Test (BMD Test) Measures bone density at various sites Helps determine risk for fractures Understanding your risk factors is important, but having a bone mineral density test (BMD Test) is the most effective way to understand if you actually have osteoporosis. There are different types of BMD testing. Bone density can be measured at one or more sites on your body, such as your spine, hip, foot, or wrist. Your BMD test score, called a T-Score, can help your doctor understand whether you have osteoporosis.

What kinds of BMD tests are there? DEXA (dual energy x-ray absorptiometry) Gold standard Measures hip, and spine Compares bone density to that of a young adult (T-score) Peripheral measures (ankle, hand, finger) A screening tool Indicate possible risk of future fracture The gold standard in BMD testing is called a DEXA (pronounced decks – ah) which stands for dual energy x-ray absorptiometry. It can measure at the hip and spine, and compares bone density to that of a young, healthy adult. This result is called a T-score. Other BMD tests use peripheral measures such as at the ankle, hand, or finger. This is best used as a screening tool to indicate possible risk of future fracture.

Who Should Get a Baseline Bone Density Test? National Osteoporosis Foundation Recommendation: All women 65 years old or older All women with a history of fragility fractures All postmenopausal women with at least one risk factor Adults with a disease or medication history associated with bone loss Who should get a baseline bone density test? A baseline BMD tests is needed to determine the health of your bones relative to a young, healthy adult of the same gender and form a basis from which to compare your future scores to understand your bone health over time. According to the National Osteoporosis Foundation (NOF), you should get a baseline if: You are a women 65 or older You are a women with a history of fracture, because this is a key risk factor If you are past menopause with at least one risk factor If you are an adult who has taken high doses of medications such as steroids for long periods of time that can cause bone loss.

World Health Organization (WHO) Osteoporosis Guidelines T-Score WHO, Guidelines for Preclinical Evaluation and Clinical Trials in Osteoporosis, 1998.

Management of low Bone Mass Vitamin D and Calcium Exercise Hormone Treatment Fosamax / Actonel / Boniva Evista / Tibolone Calcitonin PTH (Parathyroid hormone)

Vitamin D Supplementation In conjunction with Calcium Attenuation of Bone Loss Reduction of fall risk Main sources for Vitamin D: skin and milk Slows progression of Osteoarthritis

Calcium Supplementation Calcium Citrate Calcium Carbonate (Shells) Divided doses

Calcium Supplementation With Vitamin D  fracture risk reduction  tooth loss reduction Without Vitamin D  ? Reduces the rate of bone loss Premenopausal women: 1000 mg/day Postmenopausal women: 1500 mg/day

Role of dietary Calcium # servings of dairy X 300 = mg of Calcium One serving: 8 oz milk (240 cc) 8 oz Yogurt 16 oz cottage cheese 1 oz hard cheese

Physical activity Aerobic exercise Weight bearing exercise Resistance training Bone mineral density improvement ? Fracture risk reduction

CONCLUSION Osteoporosis is the most common bone disorder It is treatable It is preventable