Osteoporosis is a systemic disease of the skeleton due to decreased bone mineral density, that leads to decreased bone mass, deterioration of bone tissue, increased bone fragility and increased risk of bone fracture. It is known as the "silent" disease because most people do not know they have it until they break a bone. Fractures occur with minimal or no trauma. Advanced disease results in progressive functional disability and impaired quality of life.

The Facts
Osteoporosis threatens the health and independence of approximately 28 million Americans. Osteopenia is the beginning of osteoporosis. It is decreased bone mineral content. People with osteopenia are at substantial risk of developing osteoporosis. Osteoporosis is responsible for 1.5 million fractures annually (300,000 hip fractures, 700,000 vertebral fractures; 200,000 wrist fractures and 300,000 other fractures). It can occur at any age, but is most common in women and in the elderly. One of every 2 women and one of every 8 men will suffer an osteoporosis related fracture in their lifetime. White women over 60 have at least 2 times the incidence of fracture caused by osteoporosis, than African-American women. Lifetime risk of osteoporotic spine, hip, and wrist fracture is 40% for white women and 13% for white men after age 50.

People who suffer a hip fracture have a 5-20% increased risk of dying within the first year after the injury. Of those living independently before hip fracture, 50% are unable to walk without assistance, and 25% require long term nursing home care one year after injury. Women experience hip fracture more frequently than men, but men die more often within the first year after injury.A woman's risk of hip fracture is equal to her combined risk of breast, uterine and ovarian cancer.

The Bones
The skeleton has many functions. One is to store the body's calcium and other essential minerals, such as phosphorus and magnesium. The skeleton holds 99% of the body's calcium. The one-percent remaining calcium is freed to circulate in the blood and is essential for crucial bodily functions. Bones are constantly remodeling themselves. Cells called osteoclasts dig holes into the bone, releasing small amounts of calcium into the bloodstream that are necessary for other vital functions. They then rebuild the skeleton first, by filling in the holes with collagen and, then, by laying down crystals of calcium and phosphorus.

There are two types of osteoporosis:

Type I, or high turnover, osteoporosis occurs in 25% to 30% of women between the ages of 50 and 75 due to the loss of estrogen postmenopause. This results in a rapid depletion of calcium from the skeleton.
Type II, or low turnover, osteoporosis results when the process of reabsorption and formation of bone are no longer coordinated meaning, bone breakdown overcomes bone build up. This occurs with age to men and women alike to some degree.

Before age 40, the process of breaking down and building up bone is a nearly perfectly coupled system, with one phase stimulating the other. However, as we age this system breaks down and the two processes become out of sync. The reasons for this are not clear. Some individuals have a very high bone turnover rate while others have a very gradual turnover, but eventually, the breakdown of bone overtakes the build-up. Over time this thins the bones, and makes them porous, causing the bones to be weakened and makes them more likely to break.

Because these patterns of reforming and reabsorbing bone often vary from patient to patient, experts believe a number of different factors account for this problem. Important hormones, such as estrogen, parathyroid, and vitamin D, as well as blood factors that affect cell growth are involved in this process. Changes in levels of any of these factors are thought to play a role in the development of osteoporosis.

Who Gets Osteoporosis?

Osteoporosis has its foundations in youth. Building strong bones before age 35 is the best defense against osteoporosis. Maximizing calcium intake in childhood, adolescence and pregnancy is critical to good bone health later in life.

What are the Causes of Osteoporosis?

Early menopause or surgical menopause caused by removal of ovaries puts women at even a greater risk. Weak thigh muscles, shortness and thinness, and poor balance increase the risk for osteoporosis as well. Menopause before age 48, not getting enough exercise, not getting enough calcium in your diet, osteoporosis in your family; hyperthyroidism, smoking, alcohol abuse, small bone frame, fair skin and use of steroids are all causes of osteoporosis.

Other risk factors that contribute to osteoporosis include:

Asthma therapy. Recent studies show that the use of asthma medications can cause osteoporosis, even in adolescent girls.

Other medications. Many medications can create conditions that reduce bone density. Long-term corticosteroids can cause calcium loss. People taking these medications should increase their daily intake of calcium and vitamin D. Other medications that affect bone mineral density include anticonvulsants, heparin, thyroid hormones, and Vitamin A.

Illness. Gastrointestinal disorders that cause malabsorption can cause osteoporosis. Cancer, connective tissue disorders, anorexia, bulimia, rheumatoid arthritis, prolonged inactivity and chronic kidney disease can all contribute to osteoporosis

Cigarettes. Women and men who smoke, have a significantly greater chance of spine and hip fractures than those who don't smoke.

Coffee. The risk of osteoporosis has been associated with heavy caffeine consumption. One study found that more than two cups of coffee or four cups of tea a day increased the amount of urinary calcium output and the incidence of hip fractures.

Being Underweight. is a risk factor for osteoporosis in both men and women.

Dietary Factors. Calcium and vitamin D deficiencies, of course, contribute to osteoporosis. A recent Swedish study indicated that high amounts of dietary vitamin A might reduce bone density. High sodium intake interferes with calcium retention. The higher the level of sodium the more calcium the body needs to meet its daily requirements. Diets deficient in protein also increase the risk for osteoporosis.

Too Much and Too Little Exercise. can also put people at risk since they may have a lower amount of estrogen in their bodies.

Lack of Sunlight. The photochemical effect of sunlight on the skin is a primary source for vitamin D. Bone formation peaks in the summer and bone breakdown increases in the winter. People who avoid sun exposure to prevent skin cancer may be at risk for vitamin D deficiency, particularly if they are elderly.

How can you prevent Osteoporosis?

Exercise
Exercise is very important in slowing the progression of osteoporosis. Low bone mass in childhood and adolescence raises the risk of osteoporosis later in life " If you don't have enough bone to begin with, you don't need very much destruction to develop osteoporosis" said panel member Keith Hruska, MD of Washington University School of Medicine. Physical activity should start early in life, which will contribute to higher bone mass later in life Exercise should begin in adolescence since bone mass increases during puberty and reaches its peak between ages 20 and 30. Weight bearing exercise, which applies tension to muscle and bone, encourages the body to compensate for the added stress by increasing bone density by as much as 2% to 8% a year. This is not suggested for the elderly but is recommended for all women before menopause. For the elderly, even moderate exercise (as little as an hour a week) helps reduce the risk for fracture.

Hormone replacement therapy
Hormone replacement therapy is one of the best ways to keep osteoporosis from getting worse, once it has started. And, if taken at the time of menopause, in combination with calcium and vitamin D, it can prevent osteoporosis. If hormone replacement therapy is stopped, your bones start to lose calcium. The longer you take hormone replacement therapy, the less likely you are to get osteoporosis.

Dietary Factors

Calcium
Calcium Supplements of calcium can help maintain bone density and reduce the risk of fracture in both men and women. A study in Yugoslavia showed that people who maintained a high calcium intake during their lifetimes have fewer fractures and are less at risk. Another study reported that calcium slowed bone loss in portions of the hips where fracture is most serious. Calcium intake is especially important in childhood and adolescence when the maximum bone density is established.

Many researchers have suggested a higher calcium intake for postmenopausal women since they have a lower level of estrogen. Experts recommend that women after menopause need up to 1,500 mg. of calcium a day, if not taking estrogen. Before menopause, experts suggest getting 1,200 mg. per day. A study showed that doses as low as 1000 mg/day prevented bone loss during winter months (when bone loss is greatest) in postmenopausal women who did not have osteoporosis. The best source of calcium in the diet is from milk fortified with vitamin D. Vitamin D helps your body absorb calcium. If you can't consume enough calcium through your diet consult your local nutritionist on which type of calcium supplement is good for you. A low intake of calcium coupled with a high intake of nondairy animal protein, is particularly associated with an increased risk of hip fractures in women. Many studies suggest that calcium should not be restricted to prevent kidney stones because it can promote osteoporosis.

Throughout the life cycle you have different calcium needs. The National Osteoporosis Foundation recommends the following daily calcium intakes:

· 1,300 mg. Ages 9-12
· 1,000 mg for adult men and women ages 19-50;
· 1,200 mg for men and women over 50;
· 1,300 mg for pregnant and lactating women younger than 18
. 1,000 mg. for pregnant and lactating women over 18
· 1,500 mg for post-menopausal women who are not on estrogen replacement therapy.

Vitamin D
Vitamin D is an essential companion to calcium in maintaining strong bones. It is manufactured in the skin using energy provided by ultraviolet rays from sunlight and is necessary for the absorption of calcium in the stomach and gastrointestinal tract. If you live in a climate where there is little sunshine in the winter months, you need to take Vitamin D in supplement form.

A study from France, by Marie C. Chapuy et al. published in the New England Journal of Medicine , looked at the benefits of calcium and vitamin D supplementations on hip and other fractures. They studied 3,270 women, 69 to 100 years of age. For 18 months, their diets were supplemented with a special calcium mixture plus 800 units of vitamin D3. At the end of the study, the number of hip fractures were 43% lower and the number of nonvertebral fractures were 32 % lower in the women treated with calcium and vitamin D than those who received the placebo. This is a good reason to watch your calcium and vitamin D intake. Another study reported in the New England Journal of Medicine that lasted 3 years and involved 176 men and 213 women, 65 years or older reported similar results.

Magnesium
Magnesium is a key nutrient for the proper functioning of the nerves and muscles. It is also necessary for the healthy maintenance of bones. Magnesium is often coupled with calcium in supplements because of its synergistic effects (it helps the body absorb the calcium better). According to Mildred S. Seelig, PhD, ( a magnesium expert from the University of North Carolina), more than half of the body's magnesium is found in the bones. Calcium gives bones their strength, while magnesium helps them maintain their elasticity to prevent injury. This is a good reason to make certain to have a good calcium-magnesium ratio in your daily diet.

Low levels of magnesium may contribute to thinning bones. According to a 1998 study, magnesium supplements help suppress the cycle that leads to bone loss. Experts suggest the level of magnesium needed each day is about 400 to 800 mg. Magnesium should also be taken at a 1:1 and 2:1 ratio of calcium.

The more calcium in the diet, the more magnesium needed. Calcium given alone can induce magnesium deficiency. The most serious complications from a deficiency of magnesium are heart conditions such as irregular or rapid heartbeat Guy E. Abraham MD has data showing that magnesium deficiency plays a significant role in primary post-menopausal osteoporosis. Magnesium is involved in calcium metabolism and in the synthesis of vitamin D, as well as in maintaining bone integrity. In the Medical Tribune, Gustawa Stendig-Lindberg, MD, of the Sackler School of Medicine at Tel Aviv University, reported that in postmenopausal women, bone density drops by 1% per year. It is believed that magnesium may halt the loss of bone because it aids in the transport of calcium in and out of the cells. Magnesium also plays an important role in converting vitamin D to its active form .

Boron
Boron, a trace mineral, has been making nutritional medicine news very recently, and will likely be noted as the next essential trace mineral. It appears to help maintain calcium balance, keeping bones healthy and preventing osteoporosis. The most recent research elucidates the positive health benefits of adequate dietary boron. Researchers at the U.S. Department of Agriculture found that boron plays a key role in calcium and magnesium loss by helping the body synthesize both estrogen and vitamin D. This is good news for people of any age who want to prevent osteoporosis, arthritis and other bone weakening conditions.

The level of dietary boron needed is between 3 and 5 mg. daily. It has been recommended that, because of its positive benefits, the elderly and anyone at risk of osteoporosis should eat boron-rich foods and further supplement boron at a level of about 1-3 mg. daily. The highest concentration of boron in the body is in the parathyroid glands, suggesting its tie to calcium metabolism and bone health. Boron in fruits and vegetables is readily available and easily absorbable.

Which is the best form of Calcium?

Calcium Citrate. There are many different sources of calcium. Three important new studies from UT Southwestern Medical Center at Dallas Researchers have shown that calcium citrate is the better absorbed than any other calcium and is effective at preventing osteoporosis in early post-menopausal women. Dr. Khashayar Sakhakee and colleagues published their analysis of data from 15 previously published randomized trials evaluating bioavailability (the amount of calcium absorbed from a supplement, rather than the amount of calcium a supplement contains) in the 1999 November - December issue of the American Journal of Therapeutics. They reported that calcium citrate was absorbed 22-27% better than all other forms of calcium.

A second study published in 1999, by Dr. Howard Heller, in the November issue of the Journal of Clinical Pharmacology compared the absorption of calcium citrate versus calcium carbonate. They measured blood calcium concentration instead of urine calcium excretion and found that calcium citrate was more effective.

The third study published in the December issue of the American Journal of Therapeutic, by Dr. Lisa Ruml, also compared the effect of calcium citrate vs. a placebo in preventing bone loss in early post - menopausal women over a two-year period. During this study, 57 women in early post-menopausal (5 years into menopause) and six mid- menopausal women (5-10 years into menopause) took either 800 milligrams of calcium citrate or a placebo daily.

Those taking calcium citrate averted bone loss by stabilizing the bone density in their spine, in the top part of their thigh-bone (a common sight for hip fracture) and in the small bone of the forearm. Women taking the placebo had a significant decline, over the 2-year period, in the densities of the spine and forearm but showed no changes in their thighbone density.

These studies confirm the health benefits of calcium citrate. It is the most well absorbed and most effective form of calcium to prevent osteoporosis.

SOURCE: American Journal of Therapeutics 1999;6:303-311,313-321. Journal of Clinical Pharmacology 1999;39:1-4.

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*The information provided is for educational purposes only. These statements have not been evaluated by the FDA. This product is not intended to diagnose, treat, prevent or cure any disease or condition.
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References:

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Osteoporosis and Related Bone Diseases- National Resource Center (ORBD-NRC). Osteoporosis. Available at: http://www.osteo.org/ostes.html June5,1997.
National Institute on Aging (NIA). Age Page: Osteoporosis: the silent bone thinner. Available at : http://www.nih.gov/nia/health/pubpub/osteo.htm June 5, 1997.
Riggs BL, et al. "The worldwide problem of osteoporosis: insights afforded by epidemiology." Bone 17 (5 Suppl):505S-511S, 1995.
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(Stendig-Lindberg,G, MD: Medical Tribune: July 22, l993.)

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