Osteoporosis
By Jody Vulk PA-C
Northwest Iowa Bone, Joint
& Sports Surgeons
Osteoporosis
“Porous bone“
Bones lose protein & mineral content
Clinical Definitions of OP
Vertebral height loss of > 25% of the
vertebral body
2 compression fractures
2 or more fragility fractures
FRAGILITY FRACTURES

A fracture from forces that
would not ordinarily cause
fracture in a healthy young
adult.

Quantified as forces equivalent
to a fall from a standing height
or less.
Types of Fragility Fractures

Compression Fractures of the Vertebra


Proximal Humerus
Distal Radius Fractures

Hip Fractures
True or False
Most Common Fragility Fractures are:
#1 Spine
#2 Wrist
#3 Hip
True
Spine 27%
Wrist 19%
Hip 14%
Bone Cells
Osteoclasts
■
■
Remove or retire old
bone.
Active throughout
lifetime.
Osteoblasts
■
■
Create new bone
Best before age 35 &
before menopause
Osteoclasts
Osteoblasts
Remove Old Bone
(Classic)
Create new bone
(having a Blast!)
In Osteoporosis
More of these working…
than these.
Osteoclasts
■
■
Remove or retire old
bone.
Active throughout
lifetime.
Osteoblasts
■
■
Create new bone
Best before age 35 &
before menopause
Dual Energy X-ray Absorptiometry
BMD Levels
Normal = 0 to 0.9 T-Score
Osteopenia = 1 to -2.4 TScore
Osteoporosis =
-2.5 T-Score
Who needs a BMD?

A woman nearing menopause
(for baseline)

Men over the age of 70

Women 65 or older
(& have never had one)

Those with risk factors for osteoporosis
How often to Test

Normal BMD=15 years

Osteopenia=5 years

Severe Osteopenia=1 year

85 or older=3 years
Bone
Minerals
True or False
To avoid
Osteoporosis--
just is drink more milk.
False
Calcium + Vitamin D +
Magnesium+
Phosphorus + Alkaline
Phosphatase =
Good Quality Bones
Foods for Healthy Bones
10001500mg
Daily
Calculate
Need
Calcium supplements
Calcium Citrate
 Take
food
 21%
with or without
Calcium
 More
frequently
causes gas, bloating,
constipation
Calcium Carbonate
 Requires
stomach acid,
take with food
 40%
Calcium
 Fewer
side effects
 Inexpensive
Calcium
Zappers
Osteoporosis & Vitamin D
Deficiency
1
 1/3
Billion worldwide
of OP patients also Vitamin D
deficient
 Vitamin
D deficiency is not age
dependent.
Vitamin D is created through the skin by exposure
to sunlight
Vitamin D and Sunlight
You must live near the equator to rely on its benefits.
True or False
Caucasians are more prone to Vitamin D
deficiencies than those with darker skin.
False
Darker skin does
not absorb
Vitamin D as well.
Vitamin D Rich foods
Fatty fish
*Cod Liver oil(1360 IU)
Swordfish(566 IU)
Salmon(sockeye)(447 IU)
Tuna(154 IU)
Fortified foods:
Milk (115 IU)
Orange juice
(137 IU)
*avoid Cod liver oil
Egg yolks (41 IU).
Vitamin D Supplements
Cholecalciferol
(Vitamin D3)
Ergocalciferol
(Vitamin D2)


Fungal
derivative

Synthesized in the skin

Vegan
supplement

Wool oil
Preferred supplement
Age
Dosage
*400 to 800 IU daily
New Guidelines
Adults < 50
Adults > 50
*800 to 1,000 IU daily
Normal Vitamin D level, do not exceed 4,000IU
daily.
*Do not commit these to long term
memory, follow-up research
pending.
Vitamin D Deficiency Risk Factors
Risk Factors of Vitamin D deficiency


Northern Latitudes

<15 minutes of sun
African American, or dark skinned


Elderly
Obesity
Vitamin D

Vitamin D is fat soluble, stored in fat
Testing is on blood
Loose weight, boost Vitamin D


Who is at risk?
True or False
Men do not need to be tested for Osteoporosis.
False


2 million men have
OP
Men are more likely
to die in the first year
after hip fracture.

Men who fracture
are less likely to be
tested.
Early Signs of Osteoporosis
Joan Surber

Age 68

Pelvic Fracture
1/28/2012

T-Score of -2.5 in
her Lumbar Spine, 1.8 in the Right hip
and a -2.2 in the
Left hip.

Vitamin
D=12ng/mL
Severe Osteoporosis
T-score –2.5 or less
&
a fragility fracture has occurred.
Leg braces as a child
Calcaneus Fracture at
age 42
Menopause at age
34
20+ year history of
GERD with medication
use
Risks factors & Prevention
Heredity/Ethnicity
Don’t have it in your genes
Hormonal Changes
(Estrogen & Testosterone)
Hormone replacement (at
the guidance of your PCP)
Aging
Not recommending to avoid
this one.
Pharmaceuticals
Avoid long-term use of bone
depleting medications
(Cont.) Risk Factors & Prevention
Low BMI
History of
Fracture
EAT! -a diet rich in
colors and eat real
foods!
Bubble wrap
(Cont.) Risk Factors & Prevention
Malabsorption
Poor Diet
Smoking
Alcohol in excess
Lack of Exercise
Avoid Gastric Bypass, Celiac
Sprue, Anorexia…
Eat FOODs rich in Vitamins
and minerals
Don’t do that!
Limit alcohol to no more than
2 beverages daily
Weight bearing exercises such
as walking, tia chi, & weight
lifting/resistance exercises
Types of Osteoporosis
Primary
Secondary
Relatively unknown
cause other than
advancing age
and
postmenopausal
Has a known cause
or reason for having
developed (i.e.=oral
corticosteroid use,
other medications,
diseases or
conditions)
True or False
Kyphosis of the spine is “normal for aging.”
False
Decreasing height and humped back are
not normal. They are indications of
compression fractures.
NWIA Bone
Approach
But orthopedists fix bones, Right?
We Evaluate
Anyone over 50 with a fractured
bone from ground height.
Own The Bone
 Nutrition Counseling
•
•
Calcium
Vitamin D
 Physical Activity Counseling
•
•

Lifestyle Counseling
•
•

For the treatment of osteoporosis
Testing
•

Smoking Cessation
Limiting excessive alcohol intake
Pharmacology
•

Weight-bearing and muscle-strengthening exercise
Fall prevention education
Dual Energy X-Ray Absorptiometry (DXA)
Communication
•
•
Physician referral letter
Follow-up note and educational material to patie
Step-wise Approach
Initially After a Fracture






Remove Bisphosphonates
Fracture immobilization/
fixation
Draw Labs/BMD
Vitamin D Correction
Heal the Fracture
Step-wise Approach
Through the OP Clinic





Check Vitamin D
Increase bone mass if warranted
Fracture Risk Assessment
Educate patients on calcium,
Vitamin D, exercises
Resume Bisphosphonates
Medications
National Osteoporosis
Foundation
Recommends treatment:
T-score is less than -2.0
Or
Less than -1.5 with a risk factor
(after the fracture has healed )
Medication
Route and Frequency
Use
Alendronate
Oral; Daily or Weekly
Prevent/Manage
avoid in
Hyperparathyroidism
or Renal Dysfunction
Calcitonin
Intranasal; Daily
Management
Ibandronate
Oral or IV;
Daily/Monthly/q 3
mo.
Prevent/Manage
avoid in
Hyperparathyroidism
or Renal Dysfunction
Raloxifene
Oral; Daily
Prevent/Manage
+Breast CA
prevention
Risedronate
Oral; Daily or Weekly
Prevent/Manage
avoid in
Hyperparathyroidism
or Renal Dysfunction
Teriparatide
Injection; Daily
Management
Denosumab
SubQ; q 6 mo.
Management +Breast
CA prevention
Zoledronic acid
Injection; yearly
Management
Exercises
True or False
Swimming is a great exercise to prevent
osteoporosis.
False
Swimming does not prevent osteoporosis. Only
weight bearing exercises prevent osteoporosis.
Balance Training & Good Posture
Resistance Training & Stretching
Weight Bearing Exercise
Review
Calcium + Vitamin D + Magnesium+
Phosphorus + Alkaline Phosphatase =
Good Quality Bones
Vitamin D3
Calcium
Carbonate
Game Time
#1
What are the top three types
of compression fractures?
#1) Spine 27%
#2) Wrist 19%
#3)Hip 14%
#2
What are the top three definitions
of clinical osteoporosis?
Clinical Definitions of OP
#1) Vertebral height loss of > 25% of
the vertebral body
#2) 2 compression fractures
#3) 2 or more fragility fractures
#3
What are the top objective
(laboratory/radiological)
definitions of good bone
health?
(I have 6 answers)
Good Bone Health
 BMD
with T-score from 0- 0.9.
 Vitamin D > 30ng/mL
 Calcium (within local lab normal limits)
 Magnesium (within local lab normal limits)
 Alkaline Phosphatase (within local lab normal limits)
 Phosphorus (within local lab normal limits)
#4
List the top sources of
Vitamin D.
(7 were listed)
Vitamin D sources
1. Sunlight
2. Cod liver oil
3. Swordfish
4. Salmon
5. Tuna
6. Fortified Milk
7. Fortified Orange Juice
(Eggs also pictured)
#5
What are some great
exercises for preventing
bone loss?
(I have listed 6)
Exercises to prevent bone loss
 Walking
 Yoga
 Tai
Chi
 Weight or Strength/Resistance training
 Balance training
 Good Posture
#6
What are the top risk factors
for developing OP?
( I discussed 11)
OP Risk Factors
1. Hereditary/ Ethnic background
2. Hormonal changes
3. Age
4. Medications
5. Low BMI
6. Previous Fractures
7. Malabsorption
8. Poor diet
9. Smoking
10. Alcohol
11.Lack of exercise
References
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Adi Cohen, MD, MHS Columbia University, May 18-21,2011 Osteoporosis in Premenopausal Women: diagnosis and
Treatment Issues, ISO9 course, Las Vegas Nevada.
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"Clinical Practice Comparison of Clinical Efficacy and Safety between Denosumab and Alendronate in
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Aug. 2011.
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References (Continued)
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"International Osteoporosis Foundation | Bone Health." International Osteoporosis Foundation | Bone
Health. International Osteoporosis Foundation, Jan. 2011. Web. 03 Mar. 2012.
<http://www.iofbonehealth.org/>.
Calcium rich foods
Livestrong. "What Foods Raise Alkaline Phosphatase Levels." Livestrong.com. N.p., n.d. Web. 20 Mar. 2012.
Mason, Moya K. "Calcium." Moyak.com. N.p., 2012. Web. 20 Mar. 2012.
Mosner, RD,CDN, Michelle. "NYSOPEP." Community Education. Proc. of International Symposium of
Osteoporosis, Las Vegas. N.p.: n.p., n.d. N. pag. Print.
NIH Consensus Development Panel. "Osteoporosis Prevention, Diagnosis, and Therapy." NIH Consensus
Development Program. U.S. Department of Health and Human Services, 27 Mar. 2000. Web. 22 Mar. 2012.
<http://consensus.nih.gov/>.
NIH. "Dietary Supplement Fact Sheet: Magnesium." Ods.od.nih.gov/factsheets/magnesium. National Institute
of Health, n.d. Web. 20 Mar. 2012.
NIH. "Vitamin D Factsheet." Nih.gov. N.p., n.d. Web. 22 Mar. 2012.
NOF. "About Osteoporosis | National Osteoporosis Foundation." About Osteoporosis | National Osteoporosis
Foundation. N.p., n.d. Web. 30 Apr. 2012. <http://www.nof.org/aboutosteoporosis>.
NOF. "Why Bone Health Is Important | National Osteoporosis Foundation." Why Bone Health Is Important |
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Watts, Dr. Nelson ,MD Bone Health and OP Center University of Cincinnati, May 18-21, 2011 International
Symposium of Osteoporosis, Las Vegas, Nevada (IOF course)