Features

Osteoporosis: the silent disease

18 September 2020

A bone fracture is often the first indication of this typically asymptomatic common condition, writes journalist Julie Penfold.

Around three million people are living with osteoporosis in the UK and many more could have the condition but don’t know it (NHS, 2019).This lack of knowledge could, in part, be due to the closure of many NHS healthcare services during the Covid-19 pandemic, including diagnostic screening for osteoporosis. The Royal Osteoporosis Society (ROS) fears this backlog could lead to longer-term delays for diagnosis and subsequent treatment.

‘The main issue is that there has been no DEXA [dual energy X-ray absorptiometry] bone density scans done for months,’ says Mayrine Fraser, osteoporosis nurse specialist at the ROS. ‘It’s going to take a long time for services to catch up with appointments, and we’re also aware that some people haven’t been able to get their intravenous treatments during the pandemic. We fear there are going to be big delays for quite some time.’

What is it?

Osteoporosis is a condition in which bones lose their strength and are more likely to break. This usually happens following a minor bump or fall and results in a fragility fracture. Although fractures can happen in various parts of the body, the wrists, hips and spine are the most commonly affected sites. Every year, more than 500,000 people in the UK receive hospital treatment for fragility fractures as a result of osteoporosis (Svedbom et al, 2013).

‘It’s a skeletal disease that is characterised by low bone mass and changes in the bone tissue,’ explains Mayrine. ‘This leads to increased bone fragility, making fractures more likely. Worldwide, one in three women and one in five men over 50 will experience osteoporotic fractures [International Osteoporosis Foundation, 2017].’

A bone fracture is the most common warning sign, but height loss or curvature of the spine can also suggest the condition. ‘People with osteoporosis can develop fractures in the spine, sometimes without pain and without trauma,’ explains Mayrine. ‘Fractures can happen incidentally and that’s why it’s known as the silent disease. They can happen without people realising.’

Premenopausal women are also at risk of osteoporosis, particularly if their menopause began early (before the age of 45) or they have had their ovaries removed.

Pregnancy-associated osteoporosis is a rare condition where bones can break easily. Fractures usually occur in the spine or occasionally the hip, around the time a woman is giving birth. They can also occur eight to 12 weeks following delivery. The condition tends to be more common in first pregnancies, though it can sometimes occur in subsequent pregnancies after a normal first pregnancy. It’s unclear why this happens (ROS, 2020).

Osteoporosis most commonly occurs in postmenopausal women, men over 50 and in patients taking long-term corticosteroids. But osteoporosis can also affect young men and women and children (see Risk factors, right). For example, idiopathic osteoporosis can occur in younger men and women.

Osteopenia or osteoporosis?

Osteopenia is the stage before osteoporosis. This is when a bone density scan identifies that a person has lower bone density than the average for their age.

‘For many people, osteopenia is just a normal part of ageing,’ explains Mayrine. ‘Peak bone density occurs around the age of 30 and stays relatively stable between the ages of 30 and 40 and then starts to decrease. But women tend to lose bone at a more rapid pace than men, particularly in the period immediately following the menopause. This is because oestrogen deficiency plays an important role in the bone loss process. In the first five years after the menopause, women can lose around 20% of their bone density. It’s mainly women that will go into the osteopenia zone but some of these women and men too, will go onto get osteoporosis. While people with osteopenia are more at risk, not everyone that has osteopenia will get osteoporosis.’

To determine if a person has low bone density and whether this indicates osteopenia or osteoporosis, diagnosis is made via a bone density scan. This measures a person’s T score based on the standard deviation (SD) from a healthy young adult. The World Health Organization classifies T scores as:

  • Above -1.0 SD is normal
  • Between -1.0 and -2.5 SD is defined as mildly reduced bone mineral density (osteopenia)
  • At or below -2.5 SD is defined as osteoporosis

‘There’s quite a big range between the two conditions,’ explains Mayrine. ‘For example, if you had a bone density scan at 70 and your T score was -2 or -2.3, the chances are that with time, you would go on to get osteoporosis. Whereas, if someone was diagnosed with osteopenia but their T score was -1.4, then the likelihood is they would never get osteoporosis.’

Many people are unaware they have the condition until a bone fracture leads to them having a DEXA scan at hospital or via their local fracture liaison service if they are over 50.

While some people find the disease has little impact on their lives, others are not so fortunate, particularly those that experience vertebral or hip fractures.

‘Vertebral fractures can cause height loss and curvature of the spine and this deformity of the spine can be quite painful and problematic,’ explains Mayrine. ‘For those that break their hip as a result of having osteoporosis, life may never be the same again. Only a minority completely regain their previous abilities and increased dependency and difficulty walking means that a quarter of people will need long-term care.’  

Building bone mass

While genetics undoubtedly has a role in affecting the early bone mass we have, children and young people can take big strides to build their bone mass through physical activity.

‘Childhood and adolescence is a really important time for accumulating bone mass,’ says Dr Katherine Brooke-Wavell, senior lecturer in human biology at the University of Loughborough. ‘Having a higher peak bone mass in your 20s and 30s can help to keep your bones strong as you get older. If all children and young people are regularly active, this can help to reduce their risk of osteoporosis later down the line.’

A great way to build bone mass in children and adolescents is via brief but rapid or dynamic movements, says Katherine.

‘Gymnastics is a prime example because you land hard and load both the upper and lower body,’ she says. ‘People that have done gymnastics in childhood tend to have higher bone density. Other types of exercise might include dynamic sports like football or activities that include jumping or skipping.

A study in the USA asked children to jump from a block in PE lessons three times a week over one school year. Researchers tracked the children for the next seven years and found they still had stronger bones as a result. If children spent a few minutes several times a week in dynamic activities, this would benefit the skeleton as well as having a host of other health benefits.’

Treatment and prevention

Oral bisphosphates including alendronicacid and risedronate sodium are often first-line treatments for osteoporosis in men and for postmenopausal osteoporosis due to their broad spectrum anti-fracture efficacy. They can help to reduce occurrence of vertebral, non-vertebral and hip fractures. Intravenous biphosphates include zoledronic acid and denosumab. Hormone replacement therapy is an additional option, but this is generally restricted to younger postmenopausal 
women with menopausal symptoms who are at high risk of fractures (NICE, 2020b).

Calcium and vitamin D supplements along with lifestyle changes are routinely used to manage the condition. Patients are advised to increase their physical activity, stop smoking and maintain a healthy weight to improve their bone health and reduce the risk of fragility fractures. Ensuring the diet includes an adequate intake of calcium and vitamin D is also recommended.

Mayrine feels school nurses have a key role to play in promoting lifestyle advice around healthy eating, getting outdoors and being active as these are especially important for children and adolescents while they are building bone mass. ‘If school nurses could signpost to us that would be really helpful as osteoporosis is a condition that affects people in different ways. We also offer a nurse-led helpline, and I’d like to highlight that it’s not just for people living with osteoporosis, it’s for health professionals too.’


Risk factors

There is no single cause of osteoporosis but a number of factors can increase an individual’s level of risk. These include:

  • Age (being over 50)
  • Low body mass index (BMI)
  • Family history of hip fractures
  • A previous fracture at a site characteristic of osteoporotic fractures
  • Early menopause
  • Cigarette smoking
  • Excess alcohol intake
  • Lack of physical activity
  • Vitamin D deficiency
  • Low calcium intake

Some diseases are also known to be associated with osteoporosis such as rheumatoid arthritis, hyperthyroidism, Crohn’s, coeliac disease and diabetes. An underlying medical condition or certain medications (such as steroids) that can cause bone loss can lead to what’s known as secondary osteoporosis.
NICE, 2020a


Osteoporosis in children

In children, low bone strength leading to osteoporosis is often due to the presence of an underlying medical condition. These include:

  • Inflammatory conditions such as juvenile arthritis or Crohn’s disease
  • Anorexia nervosa and nutritional problems
  • Long-term high-dose oral corticosteroid/glucocorticoid, used to treat asthma and arthritis
  • Leukaemia
  • Conditions that result in reduced mobility such as cerebral palsy
  • Delayed puberty due to conditions resulting in low levels of sex hormones

Osteoporosis in children, which is rare, can also develop as a result of osteogenesis imperfecta (also known as brittle bone disease) or idiopathic juvenile osteoporosis (IJO). With IJO, often no clear cause can be found. 


Resources  

Picture Credit | Getty


References:

British National Formulary for Children/National Institute for Health and Care Excellence (2020) 5. Bone metabolism bnfc.nice.org.uk/treatment-summary/bone-metabolism.html (accessed 6 August 2020).

International Osteoporosis Foundation. (2017) Facts and statistics. See: https://www.iofbonehealth.org/facts-statistics (accessed 7 August 2020).

Leal J eta l. (2016) Impact of hip fracture on hospital care costs: a population-based study. See: https://link.springer.com/content/pdf/10.1007/s00198-015-3277-9.pdf (accessed 7 August).

NHS. (2019) Osteoporosis. See: nhs.uk/conditions/osteoporosis (accessed 6 August 2020).

NICE. (2020a) Osteoporosis treatment summary. See: bnf.nice.org.uk/treatment-summary/osteoporosis.html (accessed 6 August 2020).

Royal Osteoporosis Society. (2020) Pregnancy associated osteoporosis. See: theros.org.uk/information-and-support/understanding-osteoporosis/pregnancy-associated-osteoporosis (accessed 6 August 2020).

Royal Osteoporosis Society. (2020) Osteoporosis in children. See: https://theros.org.uk/information-and-support/understanding-osteoporosis/osteoporosis-in-children (accessed 6 August 2020).

Svedbom A, Hernlund E, Ivergard M et al. (2013) Osteoporosis in the European Union: a compendium of country-specific reports. Archives of Osteoporosis 8(1-2): 137.

Van Staa TP, Dennison EM, Leufkens HG, Cooper C (2001). Epidemiology of fractures in England and Wales. Bone. 29(6)517-22

 

 

 

 

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