Prevention

Genetic factors play a significant role in determining whether an individual is at increased risk of osteoporosis. However, lifestyle factors such as diet and physical activity also influence bone development in youth and the rate of bone loss later in life.

With the size of our skeleton and the amount of bone contained in it changing significantly throughout life (read more in Bone Biology), overarching objectives for good bone health at various stages of life are [1]International Osteoporosis Foundation: Healthy nutrition, healthy bones: How nutritional factors affect musculoskeletal health throughout life. 2015; Available from: https://www.osteoporosis.foundation/educational-hub/files/thematic-repo…

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  • To achieve genetic potential for peak bone mass for children and adolescents
  • To avoid premature bone loss and maintain a healthy skeleton for adults
  • To prevent and treat osteoporosis for seniors.

In the broadest sense, the population can be subdivided into two distinct groups with respect to future fracture risk:

  • Individuals without a history of fragility fracture: the primary prevention population
  • Individuals with a history of fragility fracture: the secondary prevention population

Read more in models of care 

The secondary prevention population is by definition a high fracture risk group. Individuals with a fragility fracture history should undergo clinical assessment and be offered osteoporosis treatment, where warranted. 

Disease models developed for several European countries have estimated the proportion of women aged 50 years and over who have sustained at least one fragility fracture [2]Harvey, N.C., et al., Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures. Osteoporos Int, 2017. 28(5): p. 1507-1529.

. This ranges from 10% in France to almost 23% in Sweden. This highlights the fact that at any point in time, the majority of older people lack a fracture history. As such, tools to stratify fracture risk across the highly heterogeneous primary prevention population are required. In this regard, the advent of absolute fracture risk calculators such as FRAX® provide a platform to readily identify individuals who should undergo further clinical assessment [3]World Health Organization Collaborating Centre for Metabolic Bone Diseases University of Sheffield UK: FRAX® WHO Fracture Risk Assessment Tool. 2016; Available from: https://www.sheffield.ac.uk/FRAX/.

. Read more on FRAX®.

Building strong bones starts in the womb and during childhood, and thus a healthy diet and lifestyle during pregnancy and childhood is very important and it is never too early to invest in bone health.

The prevention of osteoporosis begins with optimal bone growth and development in youth. Bones are living tissue, and the skeleton grows continually from birth to the end of the teenage years, reaching a maximum strength and size (peak bone mass) in early adulthood, around the mid-20s. The prevention of osteoporosis begins with optimal bone growth and development in youth. As such, it is important that children and adolescents:

  • Ensure a nutritious diet with adequate calcium intake 
  • Avoid protein malnutrition and under-nutrition
  • Maintain an adequate supply of vitamin D
  • Participate in regular physical activity
  • Avoid the effects of second-hand smoking

It’s estimated a 10% increase of peak bone mass in children reduces the risk of an osteoporotic fracture during adult life by 50% [4]Bonjour, J.P., et al., The importance and relevance of peak bone mass in the prevalence of osteoporosis. Salud Publica Mex, 2009. 51 Suppl 1: p. S5-17.

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Bone mass acquired during youth is an important determinant of the risk of osteoporotic fracture later in life. The higher the peak bone mass, the lower the risk of osteoporosis.

Once peak bone mass has been reached, it is maintained by a process called remodelling (see bone biology). During childhood and the beginning of adulthood, bone formation is more important than bone resorption. Later in life, however, the rate of bone resorption is greater than the rate of bone formation and results in net bone loss – a thinning of bones.

Any factor which causes a higher rate of bone remodelling will ultimately lead to a more rapid loss of bone mass and more fragile bones. The nutritional and lifestyle advice for building strong bones in youth is just as applicable to adults to.

Advice for adults:

  • Ensuring a well balanced diet and adequate calcium intake 
  • Avoiding under-nutrition, particularly the effects of severe weight-loss diets and eating disorders
  • Maintaining an adequate supply of vitamin D
  • Participating in regular weight-bearing activity
  • Avoiding smoking and second-hand smoking
  • Avoiding heavy and regular drinking

 

Osteoporosis becomes more prevalent with increasing age, as bone is lost progressively throughout adult life. The very elderly are rarely assessed and treated for osteoporosis, despite significant potential benefits.

Very elderly who are mobile and in good health should be given advice on ways to improve their bone health, and whether they need specific tests and treatment for osteoporosis. Very elderly people who live in aged care establishments can be in poor health and less mobile. Many people in this group have osteoporosis or low bone mineral density, and a high fracture risk.

For the elderly:

1. Ensuring an adequate intake most importantly of protein, calcium and vitamin D

In this population there is a decrease in dietary calcium intake, usually as a result of decreased overall dietary energy intake (e.g. poorer appetite, intercurrent illnesses, social and economic factors) and a decrease in the capacity of the intestine to absorb calcium from the diet (>65), which increases the production of a parathyroid hormone that mobilises calcium from bone into the blood stream.

  • Calcium supplements can be given to the elderly when dietary are insufficient to meet the recommended intakes.

The poorer vitamin D status in the elderly is mainly due to less frequent exposure to sunlight (e.g. elderly who are housebound, institutionalized or have reduced mobility), but also because of a decrease in the capacity of the skin to synthesize vitamin D. Vitamin D deficiency not only has skeletal consequences, but is also associated with muscle weakness, an increased risk of falls and, as a result, an increased risk of fractures.

For elderly who live in nursing homes, the administration of both vitamin D and calcium supplements together reduces the incidence of fracture in those identified as deficient [5]Chapuy, M.C., et al., Vitamin D3 and calcium to prevent hip fractures in elderly women. N Engl J Med, 1992. 327(23): p. 1637-42.

[6]Geddes, J.A. and C.A. Inderjeeth, Evidence for the treatment of osteoporosis with vitamin D in residential care and in the community dwelling elderly. Biomed Res Int, 2013. 2013: p. 463589.

[7]Hill, T.R. and T.J. Aspray, The role of vitamin D in maintaining bone health in older people. Ther Adv Musculoskelet Dis, 2017. 9(4): p. 89-95.

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  1. Participating regularly in exercise activities

Regardless of age, bones and muscles need exercise to retain strength so a special exercise program tailored to the very elderly who are institutionalized is very important. Improved balance, posture, coordination and muscle strength are the benefits that result from sustained weight-bearing exercise. 

2. Preventing falls 

When osteoporosis is present, even minor trauma such as coughing, minor knocks or falls can lead to fractures. Older people have slower response times and more often fall to the side, suffering direct impacts to the hip. Their falls are often "intrinsic", or unrelated to external obstacles. They may be the result of postural instability, decreased muscular performance, malnutrition, comorbidity (e.g. poor vision, cognitive impairment) and medications.

3. Try to improve their quality of life after a first fracture

  • Pain medication and anti-osteoporotic medication should be started as soon as possible by the general practitioner or specialist.
  • Nutrition should be adequate, particularly protein intake and a calcium rich diet. A calcium supplement may be considered when dairy consumption is low, and vitamin D supplements might need to be taken when sunshine exposure or diet is inadequate.
  • Mobility can be improved with help of a physiotherapist. Physiotherapy also may decrease back pain.
  • An ergo-therapist can give advice on problems with activities of daily living or adaptations in the home.

REFERENCES

1.
International Osteoporosis Foundation: Healthy nutrition, healthy bones: How nutritional factors affect musculoskeletal health throughout life. 2015; Available from: https://www.osteoporosis.foundation/educational-hub/files/thematic-reports-2015-healthy-nutrition-healthy-bones
2.
Harvey, N.C., et al., Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures. Osteoporos Int, 2017. 28(5): p. 1507-1529.
3.
World Health Organization Collaborating Centre for Metabolic Bone Diseases University of Sheffield UK: FRAX® WHO Fracture Risk Assessment Tool. 2016; Available from: https://www.sheffield.ac.uk/FRAX/.
4.
Bonjour, J.P., et al., The importance and relevance of peak bone mass in the prevalence of osteoporosis. Salud Publica Mex, 2009. 51 Suppl 1: p. S5-17.
5.
Chapuy, M.C., et al., Vitamin D3 and calcium to prevent hip fractures in elderly women. N Engl J Med, 1992. 327(23): p. 1637-42.
6.
Geddes, J.A. and C.A. Inderjeeth, Evidence for the treatment of osteoporosis with vitamin D in residential care and in the community dwelling elderly. Biomed Res Int, 2013. 2013: p. 463589.
7.
Hill, T.R. and T.J. Aspray, The role of vitamin D in maintaining bone health in older people. Ther Adv Musculoskelet Dis, 2017. 9(4): p. 89-95.