Osteoporosis and African American women

The incidence of osteoporosis and related fractures in African American women is half that of Caucasian women. African American women who sustain osteoporosis-related fractures have increased disability and decreased survival. Given the exponential increase in hip fracture rate among African American women over the age of 70 years, the risk of osteoporosis among this population may be underestimated. This review focuses on racial differences in women's bone mineral density (BMD) and bone metabolism and on various explanations for these observed differences. Environmental risk factors for osteoporosis and related fractures among African American women and modalities for prevention and treatment of osteoporosis are discussed. African American women begin menopause with higher BMD and have lower rates of women's bone loss after menopause, which account for their decreased incidence of osteoporosis and related fractures. The risk factors for osteoporosis among African American women are similar to those found in Caucasian women. Lifestyle interventions, such as calcium and vitamin D supplementation, smoking cessation, and increased physical activity, should be encouraged to enhance peak bone mass and to decrease bone loss. These interventions and other treatment modalities, such as hormone replacement therapy, bisphosphonates, and selective estrogen receptor modulators, should be studied further in African American women.     

Effectiveness of screening for osteoporosis by bone density measurement for the prevention of fractures: a review of the evidence

To review evidence on the benefits of screening women and men for osteoporosis, a Pub Med search was performed in English papers published between 1990 and 2002. We used data from a cohort study to estimate risk of fracture from bone mineral density. Bone mineral density measured by dual X-ray absorptiometry (DXA) can predict bone fracture among elderly women, peri- and early post-menopausal women, and elderly men. It is recommended that all white women older than 65 years be screened routinely for osteoporosis. We suggest that Japanese elderly women should receive BMD measurements as a screening, but we have still issues to be solved including age from when the screening should be started, methods, and how to treat the women found to have osteoporosis at the screening. For peri- and postmenopausal women and elderly men, it might be beneficial to measure BMD as a screening and start treatment for those patients found to have osteoporosis. However, incidence of fractures for these people is lower than that for elderly women. One bone mass measurement can predict bone fracture risk for as long as over 10 years or more, but predictive ability of BMD decreases with time. Therefore, cost effectiveness needs to be reviewed to determine the benefits of screening among peri-menopausal women and men. Although bone assessment by quantitative ultra sound (QUS) method by ultrasound can also predict future fractures, only a relatively small number of longitudinal studies have been conducted in the Western countries, and there is no established evidence by means of longitudinal studies among Japanese. It is necessary in Japan to seek such evidence, however, since this method is widely used for an osteoporosis examinations.     

Osteoporosis and the risk of hip fracture

The incidence of cervical and intertrochanteric proximal femur fractures at various levels of cervical and intertrochanteric bone mineral density, respectively, was estimated by using population-based data from ongoing studies of osteoporosis and fractures among women residing in Rochester, Minnesota. Hip fractures were uncommon among women with femoral bone density greater than or equal to 1.0 g/cm2, but their frequency increased as bone density declined below that point at both femoral sites. The incidence of cervical femur fractures was estimated at 8.3 per 1,000 person-years among women with cervical bone density less than 0.6 g/cm2, while the estimated incidence of intertrochanteric femur fractures reached 16.6 per 1,000 person-years among those with intertrochanteric bone density less than 0.6 g/cm2. This new approach to the assessment of fracture risk from bone mineral density measurements indicates that osteoporosis is an important underlying cause of hip fractures.     

肌力和体力活动与骨密度关系研究进展

骨质疏松症是一种以低骨量和骨骼微结构退化为特征的骨骼疾病 ,会导致骨骼脆性增加、骨折危险性加大 ,严重威胁人类健康 ,近年来许多研究者从不同方面探索其致病因素 ,寻求预防和治疗骨质疏松症的途径。低骨密度是骨质疏松症重要的临床特征 ,本文就近年来肌力和体力活动与骨密度关系的研究状况作一综述     

Osteoporosis in women with disabilities

Women with physical and cognitive disabilities are at high risk for osteoporosis and osteoporosis-related fractures. Women with physical disabilities frequently are nonambulatory and have bone loss due to immobility. Women with cognitive disabilities have high rates of osteopenia and osteoporosis, likely partially due to high rates of anticonvulsant medication use. Women with Down syndrome are at especially high risk of osteopenia and osteoporosis, possibly because of lower peak bone density levels. Prevention of osteoporosis and related fractures in this population includes population-based measures, such as calcium and vitamin D supplementation and risk-based screening procedures. Primary care providers and specialists need to prioritize osteoporosis prevention strategies when taking care of women with disabilities. Future research is needed to determine optimal screening and prevention strategies in this very high risk population.     

Exercise interventions: defusing the world's osteoporosis time bomb

Osteoporosis is a major public health problem, affecting millions of people worldwide. The associated health care costs are growing in parallel with increases in elderly populations, and it is expected that the number of osteoporotic fractures will double over the next 50 years. The best way to address osteoporosis is prevention. Some interventions to maximize and preserve bone mass have multiple health benefits and are cost-effective. For example, modifications to diet and lifestyle can help to prevent osteoporosis, and could potentially lead to a significant decrease in fracture rates; and exercise is a valuable adjunct to programmes aimed at alleviating the risks and symptoms of osteoporosis. Practising exercise at a young age helps maximize the mineral density of bones while they are still growing and maturing, and continuing to excercise minimizes bone loss later in life. Not only does exercise improve bone health, it also increases muscle strength, coordination, balance, flexibility and leads to better overall health. Walking, aerobic exercise, and t'ai chi are the best forms of exercise to stimulate bone formation and strengthen the muscles that help support bones. Encouraging physical activity at all ages is therefore a top priority to prevent osteoporosis.     

Ethnic and genetic differences in bone mass: a review with a hereditary vs environmental perspective

Based on a review of the literature, ethnic and genetic factors are significant determinants of bone mass, along with such environmental factors as diet and exercise. Differences in bone density between blacks and whites remain even after adjustment for body mass. Black-white differences in bone mass appear to be related to ethnicity because blacks have not only greater skeletal calcium content, but also greater total body potassium and muscle mass. Genetic studies of twins and parent-offspring pairs reflect strong constitutional associations of both bone mineral content and bone density at commonly measured skeletal sites. At least for females, bone mass accumulation by age 20 y is highly associated with maternal bone mass; up to menopause it is enhanced by child-bearing and lactation; beyond menopause environmental factors seem to dominate. Dietary calcium and physical activity are significant in the control of bone mass. These findings are important for osteoporosis and fractures, especially in elderly people.     

Bone mineral density of eating disorder subgroups

Objective: We tested nine hypotheses among eating disorder subgroups and a control group on spinal bone density and investigated the relationship of their spinal bone density with a critical fracture threshold and five clinical variables—age of onset, years ill, percentage of ideal body weight (IBW), months of amenorrhea, and hours per week of exercise. Method: Dual photon absorptiometry measured spinal bone density. Results: Anorectic patients had significantly less spinal bone mass than bulimic patients with no history of anorexia nervosa or control patients. Eating disordered patients with past or present anorexia nervosa had significantly more spinal bone density values below a critical fracture threshold. Duration of amenorrhea and exercise significantly predicted spinal bone density. Discussion: Anorectic women were unlikely to reach their peak bone density, thus possibly developing osteoporosis later in life, and were likely to be at risk for nontraumatic spinal fractures. Predicting spinal bone density of anorectic women could be done by knowing their duration of amenorrhea and exercise. © 1995 by John Wiley & Sons, Inc.     

Contributions of dietary calcium and physical activity to primary prevention of osteoporosis in females.

In the United States and many Western nations, increasing prevalence of osteoporotic fracture is contributing to the health care system burden, and costs and needs for medical services are predicted to increase significantly by the beginning of the 21st century. Recent reports investigating developmental changes in skeletal mass of adolescent girls and young women under different experimental or ecological conditions support the contention that modification of environmental factors, especially dietary calcium and physical activity, can favorably modulate bone mass and bone density compared to controls. The peripubertal period, starting as early as 10 years of age, seems to be most responsive to modification of environmental/lifestyle factors, whereas potential gains of bone mass during late adolescence and early adulthood, although smaller, may be more readily achieved through improved dietary calcium intakes and regular exercise programs. Scientific evidence in support of these beneficial effects on bone is presented as part of the rationale for prevention of osteoporotic fractures. Also discussed is the need for a national policy to prevent osteoporosis through primary prevention strategies focused at young girls prior to puberty. The goal would be for every prepubertal girl, over the next decade, to achieve peak bone mass (and density) of the spine, hips and other bones by age 20, i.e., early adulthood. A second target group for national policy should be women in their 20s. Attainment of the goal to gain 3-5% additional bone mass during this decade would prolong the time before the fracture threshold range (low bone mass) is reached in the postmenopausal decades.     

Strategies for skeletal health in the elderly

Osteoporosis is a common disease in the elderly, and the fractures that result from this disorder affect 40 % of women and 14 % of men over the age of 50 years. The risk of fracture relates to bone mineral density and the risk of falling, among other factors. Low bone mineral density in the elderly can result from either low peak bone mass or accelerated bone loss, or a combination of the two. Nutritional factors play a role in both the attainment of peak bone mass and in the rate of age-related bone loss. The main determinants of peak bone mass are genetic factors, early-life nutrition, diet and exercise. Of the nutritional factors Ca, and particularly milk, are the most important contributors to peak bone mass. Some of these factors may interact; for example, a low dietary Ca in addition to an unfavourable vitamin D receptor gene polymorphism may result in low peak bone mass. The age-related changes in bone mass may also have a genetic basis, but deficiency of oestrogen is a major contributor. In addition, undernutrition is common in the elderly, and lack of dietary protein contributes both to impaired bone mineral conservation and increased propensity to fall. There is a decreased ability of the intestine to adapt to a low-Ca diet with increasing age. Other dietary factors include vitamin K, Zn and fruit and vegetables. Adequate nutritional status, particularly of Ca and vitamin D, is essential for the successful pharmaceutical treatment of osteoporosis. Thus, strategies for enhancing skeletal health in the elderly must begin in early childhood, and continue throughout life.     

广州市健康妇女骨量影响因素的初步探讨

目的:探讨影响骨质疏松的有关因素,为妇女骨质疏松症的防治提供科学依据。方法:选取在广州市居住10年以上的妇女281例,以问卷形式进行可能影响妇女骨量的有关因素调查,并测量骨密度,分析妇女骨量的影响因素。结果:腰椎BMD值与体重、BMI、运动情况成显著正相关,与生育次数成显著负相关;沃氏(Ward's)三角区的BMD值与身高、体重、BMI、营养、运动呈显著正相关,与生育次数呈显著负相关。结论:体重、营养、运动对妇女骨量有保护作用。     

Alendronate in the treatment of osteoporosis: a review of the clinical trials

Osteoporosis is a highly prevalent disease. More than half of postmenopausal women will experience fractures. Women at high risk (osteoporosis as measured by bone density, low trauma fractures of any type, or certain other risk factors) often require pharmacological therapy. However, surveys show that most women who have recently had fractures are currently not being treated. Recent results from the first megatrial of osteoporosis with >6400 participants, the Fracture Intervention Trial (FIT), have provided important advances in our understanding of osteoporosis and the efficacy of alendronate. The FIT study and other large clinical trials show that alendronate effectively increases bone density, reduces the risk of hip and vertebral fractures by approximately half within the first 12-18 months, and, most importantly, reduces the health consequences of fractures. Alendronate is also effective for preventing bone loss in early postmenopausal women. Thus, alendronate represents an important option for preventing and treating this common and debilitating disease. This article summarizes the wealth of data from FIT and other studies of alendronate in the context of the burden of illness associated with osteoporosis.     

Exercise and Nutrition Impact on Osteoporosis and Sarcopenia—The Incidence of Osteosarcopenia: A Narrative Review

Osteoporosis and sarcopenia are diseases which affect the myoskeletal system and often occur in older adults. They are characterized by low bone density and loss of muscle mass and strength, factors which reduce the quality of life and mobility. Recently, apart from pharmaceutical interventions, many studies have focused on non-pharmaceutical approaches for the prevention of osteoporosis and sarcopenia with exercise and nutrition to being the most important and well studied of those. The purpose of the current narrative review is to describe the role of exercise and nutrition on prevention of osteoporosis and sarcopenia in older adults and to define the incidence of osteosarcopenia. Most of the publications which were included in this review show that resistance and endurance exercises prevent the development of osteoporosis and sarcopenia. Furthermore, protein and vitamin D intake, as well as a healthy diet, present a protective role against the development of the above bone diseases. However, current scientific data are not sufficient for reaching solid conclusions. Although the roles of exercise and nutrition on osteoporosis and sarcopenia seem to have been largely evaluated in literature over the recent years, most of the studies which have been conducted present high heterogeneity and small sample sizes. Therefore, they cannot reach final conclusions. In addition, osteosarcopenia seems to be caused by the effects of osteoporosis and sarcopenia on elderly. Larger meta-analyses and randomized controlled trials are needed designed based on strict inclusion criteria, in order to describe the exact role of exercise and nutrition on osteoporosis and sarcopenia.     

Glucocorticoid-induced osteoporosis: pathogenesis,diagnosis, and management

Glucocorticoid-induced bone loss is dose- and duration-related, develops rapidly (within months of therapy), and leads to an increased risk of fractures. Moreover, less than one in four patients prescribed oral glucocorticoids receive any treatment to prevent or treat osteoporosis. The American College of Rheumatology recommends bisphosphonate therapy to prevent bone loss in most patients beginning long-term glucocorticoid therapy (prednisone equivalent of > or =5 mg/day for at least 3 months), and in men and postmenopausal women receiving long-term glucocorticoids who have an abnormal bone mineral density (T score below -1). Patients with glucocorticoid-induced osteoporosis are at particularly high risk for fractures, and should be treated aggressively to reduce fracture risk. Risedronate is approved in the United States for both prevention and treatment of glucocorticoid-induced osteoporosis and alendronate is approved for treatment. Both drugs increase bone mass in patients with established glucocorticoid-induced osteoporosis. Risedronate has been shown to significantly reduce the incidence of fractures after 1 year of treatment. Prevention or treatment of glucocorticoid-induced bone loss is recommended for patients at risk.     

Protocol for a randomized controlled trial to compare bone-loading exercises with risedronate for preventing bone loss in osteopenic postmenopausal women

Background

In the United States, over 34 million American post-menopausal women have low bone mass (osteopenia) which increases their risk of osteoporosis and fractures. Calcium, vitamin D and exercise are recommended for prevention of osteoporosis, and bisphosphonates (BPs) are prescribed in women with osteoporosis. BPs may also be prescribed for women with low bone mass, but are more controversial due to the potential for adverse effects with long-term use. A bone loading exercise program (high-impact weight bearing and resistance training) promotes bone strength by preserving bone mineral density (BMD), improving bone structure, and by promoting bone formation at sites of mechanical stress.

Methods/Design

The sample for this study will be 309 women with low bone mass who are within 5 years post-menopause. Subjects are stratified by exercise history (≥2 high intensity exercise sessions per week; < 2 sessions per week) and randomized to a control or one of two treatment groups: 1) calcium?+?vitamin D (CaD) alone (Control); 2) a BP plus CaD (Risedronate); or 3) a bone loading exercise program plus CaD (Exercise). After 12 months of treatment, changes in bone structure, BMD, and bone turnover will be compared in the 3 groups. Primary outcomes for the study are bone structure measures (Bone Strength Index [BSI] at the tibia and Hip Structural Analysis [HSA] scores). Secondary outcomes are BMD at the hip and spine and serum biomarkers of bone formation (alkaline phosphase, AlkphaseB) and resorption (Serum N-terminal telopeptide, NTx). Our central hypothesis is that improvements in bone strength will be greater in subjects randomized to the Exercise group compared to subjects in either Control or Risedronate groups.

Discussion

Our research aims to decrease the risk of osteoporotic fractures by improving bone strength in women with low bone mass (pre-osteoporotic) during their first 5 years’ post-menopause, a time of rapid and significant bone loss. Results of this study could be used in developing a clinical management pathway for women with low bone mass at their peak period of bone loss that would involve lifestyle modifications such as exercises prior to medications such as BPs.

Trial registration

Clinicaltrials.gov NCT02186600. Initial registration: 7/7/2014.

     

Patient assessment in the diagnosis, prevention, and treatment of osteoporosis.

Assessment of the patient with osteoporosis includes history and physical examination, laboratory testing, and imaging studies. Information gathered during this assessment assists clinicians in targeting strategies to prevent fractures. The medical history should contain items such as personal and family history of fractures, lifestyle, intake of substances such as vitamin D, calcium, corticosteroids, and other medications. The physical examination can reveal relevant information such as height loss and risk of falls. Bone mineral density (BMD), most commonly determined by dual-energy x-ray absorptiometry, best predicts fracture risk in patients without previous fracture. BMD testing is most efficient in women over 65 years old but is also helpful for men and women with risk factors. Serial BMD tests can identify individuals losing bone mass, but clinicians should be aware of what constitutes a significant change. Laboratory testing can detect other risk factors and can provide clues to etiology. Selection of laboratory tests should be individualized, as there is no consensus regarding which tests are optimal. Biochemical markers of bone turnover have a potential role in fracture risk assessment and in gauging response to therapy, but are not widely used at present. Clinicians should be aware of problems with vitamin D measurement, including seasonal variation, variability among laboratories, and the desirable therapeutic range. Careful assessment of the osteoporotic patient is essential in developing a comprehensive plan that reduces fracture risk and improves quality of life.     

The modifiable factors affecting bone mineral accumulation in girls: the paradoxical effect of exercise on bone

Amongst women in exercise training, the female athlete triad is on the increase. This is the combination of disordered eating, amenorrhoea and osteoporosis. However, the effects of exercise training on bone mineral accumulation in youngsters is not fully known. Bone mass increases rapidly during childhood and adolescence until peak bone mass (PBM) is attained. PBM is an important determinant of adult bone mineral density (BMD) and therefore optimisation of PBM is valuable in the prevention of osteoporosis. This paper reviews the effects of exercise training on the accumulation of bone mineral in girls.     

Impact of Dietary Habits and Physical Activity on Bone Health among 40 to 60 Year Old Females at Risk of Osteoporosis in India

Osteoporosis is a disorder of bones with increasing risk among women. However, a number of modifiable factors can help in combating this disorder. Present study examined the relationship of diet and physical activity and risk of osteoporosis through biochemical tests, bone mass density (BMD) scores, and standard questionnaires. Genetic risk for osteoporosis, presence of osteoarthritis, and thyroid problems were found among 8%, 7%, and 3% of participants, respectively; and 78% had onset of menopause between 47 to 55 years of age. Results revealed that less intake of proteins, minerals, and diverse fruit and vegetable consumption was significantly (p ≤ 0.05; 0.01) correlated with decreased BMD score and serum calcium. It was concluded that adequate intake of varied fruits and vegetables, good protein, habit of daily physical activity, adequate sun exposure, and dietary calcium, may play a promising role in decreasing the risk of osteoporosis among women of this age group.     

Osteoporosis Prevention: Knowledge and Behavior in a Southwestern Community

Prior to developing an osteoporosis prevention education program and social marketing campaign, we sought to (a) establish current status of osteoporosis-related knowledge and behavior among women aged 25–55 years in Maricopa County, Arizona, and (b) assess factors that segment the population by age and ethnicity. Two-hundred women were surveyed by telephone using random-digit dialing selection. Data demonstrated knowledge of need to consume adequate calcium, but mixed understanding of forms of exercise that help prevent osteoporosis. Knowledge of osteoporosis prevention did not differ as a function of menopause status. Differences for Hispanic versus non-Hispanic women's knowledge showed fewer correct responses for Hispanics for dietary and physical activity questions, and more correct responses on the relationship between body weight and osteoporosis risk. Hispanic women and post-menopausal women generally fit the pattern of higher risk behaviors with Hispanic women exercising and using HRT less and postmenopausal women reporting lower calcium intake and physical activity and more tobacco use. Hispanic women appeared to have similar intake of dietary calcium despite lower levels of milk products. Social marketing campaigns for osteoporosis prevention should be segmented for cultural and age differences, especially considering differences in orientations toward exercise, milk consumption, and competing emphasis on other diseases.     

Management of Postmenopausal Osteoporosis

Postmenopausal osteoporosis is a very common disease, and approximately half of all women aged >50 years will experience an osteoporotic fracture during the remainder of their lifetime. The predominant cause of postmenopausal osteoporosis is the decline in estrogen levels, which causes an increase in bone turnover, and results in a loss of bone mass throughout the entire skeleton. Fragility fractures, either vertebral or nonvertebral, have a considerable adverse effect on quality of life in women with osteoporosis and place a significant burden on society in terms of healthcare costs.Management of postmenopausal osteoporosis includes alteration of modifiable risk factors (e.g. lifestyle and propensity to fall), ensuring adequate calcium and vitamin D intake, and pharmacological treatment to decrease fracture risk by slowing or preventing bone loss and preserving bone strength. Raloxifene (Evista®), a selective estrogen receptor modulator that partially mimics the effects of estrogen on bone and lipid metabolism and acts as an antiestrogen in the breast and endometrium, is indicated for the prevention and treatment of postmenopausal osteoporosis. Raloxifene increases bone mineral density at vertebral and nonvertebral sites, and decreases the risk of vertebral fracture to a similar extent to the bisphosphonates alendronate and risedronate. However, effects on nonvertebral fracture risk, including the risk of hip fracture, have not been observed.Raloxifene appears to reduce breast cancer risk (in women at average risk) and cardiovascular risk (in women at increased risk) without stimulating the endometrium, and does not cause vaginal bleeding or breast pain. However, the drug causes hot flashes in some women, and increases the risk of venous thromboembolic events by about the same amount as hormone replacement therapy (HRT).In economic models, raloxifene is cost effective compared with no treatment, HRT, calcitonin, or alendronate for the prevention or treatment of postmenopausal osteoporosis.In conclusion, raloxifene is a valuable and cost-effective therapy for preventing the progression of osteoporosis and for reducing vertebral fracture risk in osteoporotic postmenopausal women. The tendency for raloxifene to cause hot flashes, and its apparent lack of effect on hip fracture risk, may preclude its use in women with vasomotor symptoms and in patients at high risk for hip fracture. Results from large ongoing trials are needed to confirm the effects of raloxifene on breast cancer and cardiovascular disease. However, the effects of raloxifene on breast cancer and cardiovascular risk without stimulating the endometrium make the drug an attractive therapy for the prevention and treatment of postmenopausal osteoporosis.