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Let's talk about Osteoporosis
Osteoporosis is an asymptomatic disease that causes bones to gradually lose their density and become fragile and brittle, which can lead to fractures.
Throughout our lives, our bodies are in constant renewal. Some cells die, others are born, in a continuous cycle of evolution and growth. The same goes for our bones. Keeping up with the new demands that our growth presents us, our bones are continually renewed, through a process of deterioration and creation of their tissues. This remodeling affects the shape and density of bones. Osteoporosis occurs when the process of creating new tissue in bones is slower than the process of deterioration and loss of old bone tissue, resulting in decreased bone mass and deterioration in bone architecture.
Osteoporosis generally develops slowly and gradually over many years and is therefore a condition commonly associated with older people (with a higher incidence in postmenopausal women). As it does not present symptoms, the diagnosis is usually late and is only made after the patient has suffered a fracture.
Worldwide, nearly 200 million women suffer from osteoporosis. And, according to the Direção-Geral de Saúde (DGS), the data compiled in recent years reveal that, in Portugal, one in three women over 50 years old suffers from this disease. According to data, around 12.2% of the Portuguese population suffers from osteoporosis, with around 17% in the female population and 2.6% in the male population. In Portugal alone, there are around 40,000 osteoporotic fractures per year, which has a huge impact on the quality of life of thousands of Portuguese people.
Osteoporotic fractures should be seen as a public health problem, due to several factors:
- the degree of incidence in the population, both in Portugal and in the rest of the world;
- the significant impact on the patient’s health, with medical consequences that directly affect their autonomy and quality of life;
- the significant economic and social impact on the patient’s life, which represents a huge cost for the patient and society.
Although data reveal a much higher incidence in older women, this is a cross-sectional disease that affects men, women, adults and children.
So far, no cure for osteoporosis has been found. We can, through prevention (diet and exercise), however, assist our body to slow down the deterioration of bones and reduce the so called symptoms of osteoporosis, osteoporotic fractures. Your doctor may also prescribe certain medications or recommend certain supplements that promote bone formation, delay bone loss, or assist in the process of reabsorbing minerals.
Osteoporosis is considered a silent disease, as it does not present directly associated symptoms. There may even be those who, despite suffering from it, never show any symptoms of the disease throughout their lives.
Generally speaking, the patient only discovers that he or she suffers from osteoporosis tardily and by one of two ways: after the occurrence of a “strange” fracture or through a specific medical examination that measures bone density, the bone densitometry exam.
Osteoporotic fractures are thus considered the main symptom of this disease. We consider these fractures to be “strange” as they are mostly caused by low-impact situations, such as a person breaking a rib after sneezing or coughing.
It is the pain caused by the fracture that alerts the patient and physician to the possibility of a diagnosis of osteoporosis, since the loss of bone density does not cause pain. It happens, however, that some fractures are very small and go unnoticed by the patient himself (such as fractures in the vertebrae of the spine), who only feel constant pain and for no apparent reason.
These small osteoporotic fractures can accumulate over time, in part due to the condition of osteoporosis itself, which delays the healing process of the fractured bone and results in deformities, the best known being the curved spine (kyphosis). This is a feature usually associated with older patients who reveal an altered posture and leaning forward, caused by weakened bones and small accumulated fractures.
Therefore, we must be vigilant and try to recognize sudden and inexplicable pain, which happens most of the time in the back area.
Our skeleton, from the moment we are born until the moment we die, undergoes a continuous process of bone tissue destruction and creation, which is closely related to the demands our life imposes on it (every three months about 10% of our skeleton is renewed).
The bone cells responsible for this renewal cycle are:
- osteoclasts – are responsible for absorbing materials and eliminating areas of obsolete bone tissue, resulting in cavities;
- osteoblasts – are responsible for creating new bone mass in the cavities opened by osteoclasts.
Our bones are hard and dense. But to maintain these characteristics, a constant and rightful supply of minerals is required, and the body must produce the correct amounts of various hormones, including the hormones of growth, parathyroid, calcitonin, estrogen and testosterone. Vitamin D is also essential for the absorption of calcium from the foods we eat and for its incorporation into bones.
Although osteoporosis is a disease mostly related to aging, with a special focus on women over 45 years after menopause, the reality is that the imbalance in the renewal of bone matter, called osteopenia, can arise at any age and in patients from both sexes.
Osteopenia is related to this imbalance between the absorption and regeneration cells (of bone matter), that is, when osteoclasts are degrading bone at a greater rate than the osteoblasts are able to replenish it. We then face an imbalance that promotes the weakening of the bone.
In women, the imbalance usually starts after age 35 and is more affected by hormonal changes associated with menopause. At menopause, women experience an abrupt drop of the hormone estrogen, which is essential in fixing calcium to the bone. This disease is usually classified as Postmenopausal Osteoporosis.
In men, as they do not go through menopause and do not suffer an abrupt drop in testosterone (which prevents bone wear), osteoporotic fractures usually only occur after the age of 70, with a gradual increase in risk after the age of 50 years.
Osteoporosis can also be developed through other diseases that the patient may suffer from or by taking certain medications and/or substances that promote the weakening of bones (eg, tobacco destroys the cells that make up bone). When this happens, its classification becomes Secondary Osteoporosis.
The main risk factors for the development of osteoporosis are:
- genetic predisposition
- certain diseases, such as:
- autoimmune diseases
- hormonal disturbances (especially Cushing’s Syndrome, hyperparathyroidism, hyperthyroidism, hypogonadism, elevated prolactin levels and diabetes mellitus)
- chronic kidney disease
- rheumatoid arthritis
- certain types of cancer (such as multiple myolema)
- nutritionally poor diet (namely calcium and vitamin D)
- sedentary lifestyle
- abusive use of medications, such as:
- thyroid hormones
- certain chemotherapy
- prolonged immobilization
The fact that certain diseases have the ability to drive the development of osteoporosis, through the imbalance of bone formation, make it important that after the diagnosis of any of these diseases, the patient should be properly monitored by a doctor in order to monitor its development .
There is also a rare type of osteoporosis that does not have any known causes, which is classified as Idiopathic Osteoporosis. This type of osteoporosis can appear in anyone, from children with healthy doses of vitamin D to pre-menopausal women, through teenagers with hormone levels considered ideal, where the only different characteristic is that their bones are weak and break more easily.
As osteoporosis is a disease difficult to recognize (due to the almost total absence of symptoms), the patient should be examined by a doctor in a routine consultation in which, through the analysis of factors such as the patient’s age, weight and height, habits of smoking and alcoholism, the use or not of corticosteroids, and also the history of osteoporotic fractures in the family, an initial diagnosis can be reached. Clinical tests should also be performed to understand the patient’s hormone, calcium and vitamin D levels, as well as kidney and liver tests.
To obtain a confirmed diagnosis, a bone densitometry exam should be performed. This painless, fast and very reliable exam allows you to see the bone from the inside and measure its mineral density, even being possible to predict the risk of future fractures. The values obtained are then compared with those of a healthy person of the same weight, sex, height and age.
Bone densitometry is an exam generally requested to:
- women over 60 and men over 70 – in the absence of risk factors;
- both sexes from the age of 45 – if there are risk factors.
Another very important fact to be taken into account during the medical consultation, together with the existence of risk factors, is the search for signs that raise suspicion for the existence of causes for secondary osteoporosis, or vertebral fractures. If any disease or risk factor for secondary osteoporosis is detected, an x-ray of the dorsal and lumbar spines should be taken to check for a vertebral deformity.
Once the diagnosis is confirmed, all treatments for osteoporosis should be done following the guidelines of a general practitioner and/or an orthopedist.
Knowing that the best treatment involves prevention, measures must be taken to change the patient’s lifestyle that promote the containment of bone mass loss and the relief of osteoporosis symptoms, such as:
- adjust the diet – adequate calcium and vitamin D intake should be promoted (or use of supplementation after a meal)
- regular physical activity – exercises such as walking, dancing or water aerobics
These measures are, in most cases when the disease is already installed, insufficient as the degeneration of the bone is superior to its reconstruction. In these cases, the physician must prescribe medication to the patient that stimulates the production of bone mass and encourages bone reconstruction, thus trying to prevent fractures.
The medication with the greatest impact on osteoporosis is the one that promotes the increase in bone mass, in which bisphosphonates are found, as they reduce the risk of fractures. Drugs that inhibit the rate of degradation of bone mass, such as calcitonin, are also used, allowing the skeleton to have the necessary time to regenerate.
If the patient has to take calcium supplementation and has kidney stones, be careful to drink plenty of water as excess calcium in the urine can be harmful and quite painful.
As already mentioned, the best treatment is prevention. This is because, often, prevention is even more successful than treatment in the case of osteoporosis.
It is easier to prevent the loss of bone density than to restore what has already been lost.
Although it is a disease largely associated with old age, the adoption of healthy eating and living habits as a method of preventing osteoporosis should start in childhood:
- adopting good eating habits – with a diet rich in calcium, which is found in milk and milk products, in broccoli and other dark green leafy vegetables and legumes, in eggs and fish rich in fat, since calcium is a essential mineral for the skeletal formation process, ensuring bone strength and participating in muscle contraction processes, in hormone release and in blood coagulation;
- vitamin D absorption – since the number of foods rich in vitamin D is reduced, and this is an essential element in the calcium absorption process, sunbathing is recommended, with the duration of 15 minutes per day (without sunscreen), during times of less heat. That way vitamin D is produced in sufficient quantity and can reach the intestine and assist in the incorporation of calcium;
- physical exercise – high-impact physical activities, such as walking or running, jumping, dancing and climbing stairs, stimulate the formation of bone mass and help strengthen muscles, ligaments and joints, which are an important factor in preventing falls. Strength training should be included, since the tendons are attached to the bones and by strengthening the tendons we also strengthen the bone itself. In the case of older people, individually adapted training programs should be designed, which include walking, muscle strengthening, posture and balance;
- avoid excessive caffeine consumption;
- avoid smoking;
- avoid drinking alcoholic beverages.
Living with Osteoporosis
With the confirmation of the diagnosis and the beginning of the treatment, measures must be taken to reduce the chances of future falls and eventual fractures.
Among these measures, you should prepare your home in order to reduce hazards, such as removing all carpets and installing a non-slip floor in the bathroom and protection bars, if necessary.
Since this is a disease that largely afflicts the elderly population, regular vision and hearing tests should be carried out, as well as working directly with a physiotherapist, in order to develop a program of exercises to strengthen the core, which improves balance, among others. Due to taking certain medications, some people experience dizziness or confusion, which leads to falls and possible fractures.
If you suffer a fracture, and after consulting with your doctor, you can try to ease the pain and aid recovery through hot and cold treatments (such as hot baths and ice packs), transcutaneous electrical nerve stimulation (TENS) treatments or relaxation techniques.
This is a disease that can lead to a great level of loss of independence and mobility, so psychological therapy is advised.
It is imperative that you talk to your doctor to understand the long-term implications of living with this condition and the possibilities for alleviating and reducing symptoms.
Goretti Tenorio e Chloé Pinheiro, “O que é a osteoporose e quais seus sintomas, tratamentos e causas”
Karolina Bergamo, “O exercício ideal para quem tem osteoporose”
Marcy B. Bolster, “Osteoporose”, MSD Manuals
Sheila Sedicias, “O que é osteoporose, causas, sintomas e tratamento”
Associação Nacional contra a Osteoporose (APOROS)
Sociedade Portuguesa de Osteoporose e Doenças Ósseas Metabólicas (SPODOM)
Sociedade Portuguesa de Reumatologia (SPR)
Instituto Português de Reumatologia